Revision as of 22:15, 28 February 2013

1 Business Purpose of the Specification
2 Business Capabilities
3 Care Collaboration - Build "Social" Network Capability Set
4 Care Collaboration - Team Conversation Capability Set
5 Care Collaboration - Participant Availability Capability Set
- 5.1 Indicate Personal Availability for Collaboration
- 5.2 Find Participant Availability for Collaboration
6 Care Collaboration - Semantic Tagging Capability
- 6.1 Tag Collaborative Content
7 Care Observations and Assessment Capability Set
8 Care Planning - Plan Life Cycle Capability Set
9 Clinical Evaluation of Plan Items
- 9.1 Check Clinical Appropriateness Capability
10 Recommend Plan Template Capability
11 Care Plan Implementation Capability Set
12 Care Review Capability Set
13 Cross-Plan Reconciliation Capability Set
- 13.1 Detect Redundancy Capability
14 Documentation Template for Capability Details

Business Purpose of the Specification

Presently in the Health Care industry, a patient may be under concurrent treatment by a variety of physicians and specialists, and each of these maintains a “plan” that suits their perspectives, purposes, and time horizons. Without mechanism to positively coordinate these plans, gaps and overlaps emerge, leading to compromised quality and efficiency of care. These stakes are especially high in cases of chronic conditions (or multiple chronic conditions, such as Diabetes plus Cardiovascular disease).

The purpose of the HSSP Care Coordination Service (CCS) is to support collaborative planning and execution of operational health care around a “coordinating” care plan that is live and shared among a multi-disciplinary care team. The care team may be dynamically managed to consist of members from either the same or different organizations (e.g. primary care clinic, home care, allied health professionals, hospital, skilled nursing facility, etc.)

There exist standards from HL7 and IHE by which specialty or episodic “plans of care” may be replicated as CDA documents or sections therein, but there is no standard structure or service that unifies them or directly supports the actual reconciliation, consolidation, and true “sharing” of the “cleaned-up” or reorganized plan.

As regards this sharing, the CCS will allow changes made or proposed by one participant to be immediately viewable by all, and will even support concurrent editing by multiple authors. With that foundation, the CCS allows a primary provider (for example) to raise a controlled discussion around a specified topic or for the case as a whole. Even a Clinical Decision Support System may participate as a first-class team member, contributing to discussions or raising new discussions.

The CCS should allow for greatly increased manageability of care plans than we now see in practice.

Business Capabilities

What are capabilities

Capabilities express "abilit[ies] that an organization, person or system possesses" [1]. Capabilities are independent of business process and business rules; capabilities express the "what" rather than the "how".

Business capabilities may outlive specific technical specifications or implementations that realize business processes. They may be represented in HL7 V2, V3 or V10 but they will endure and continue to represent what the business does and describe what services in technology X will need to perform.

The Care Coordination Service (CCS) capabilities comprise the core of the normative content specified by the HL7 SOA CCS Service Functional Model (SFM) as specified in the Health Services Specification Program (HSSP).

Capabilities may naturally fall into logical groupings which we'll also represent as UML interfaces in the informative part of the HL7 SOA SFM.

As a general rule the capabilities are independent from organizational policies and business rules. This decoupling will allow the CCS capabilities to be combined to support various business processes and organizational policies. This is key for realizing care coordination services through the continuum of care.

The road ahead:

May 2013 - Complete HL7 comments only draft
September 2013 - Complete draft standard for trial use (HL7 DSTU)for CCS service functional model
2014 - OMG technical specification work

The Problem

CCS Solution Overview

Complementary Efforts

Care Collaboration - Build "Social" Network Capability Set

Invite to Collaboration Participants

Capability Status	2-26-2012	Proposed	Reviewers Here

An invitation is a request from one individual to another to participate as collaborators in care coordination activities. Participants join the the Care Team via an invitation based process which helps to organically grow the patient's care network just as it does in the "real world".

A patient can directly invite providers and care givers to join his or her care team (as the patient is the first member of the care team).
An invitations may be sent from an any existing care team participant to new care team member.

The patient's delegated steward of their care plan, licensed independent practitioner (LIP) (e.g. PCP or other professional care plan facilitators such as a nurse case manager) will typically serve as the "seed" of the collaboration tree as they invite other providers to collaborate in care coordination.

Policies and rules regarding who is entitled to receive invitations and receive access to collaborate on patient care will continue to be dictated by existing processes (e.g. policies that allow a provider to fax clinical information to a specialist or have a phone conversation about my health conditions).

Precondition	The invitation placer must be an existing member of the patient's care team. This may include the following roles as defined in the HL7 Care Plan model: Patient Provider Care Giver Support Member
Inputs	Initiating collaborator (Role and Person/Entity details) Patient New Collaborator (Role and Person/Entity details) Collaboration Reason (e.g referral, care transition)
Outputs	none
Postconditions	New collaborator receives a secure message with request for collaboration
Exception Conditions	New collaborator not vetted by external policy checks
Included in Profiles	edit here
Outstanding Issues	edit here

Respond to Collaboration Invitation

Capability Status	2-26-2012	Proposed	Reviewers Here

A collaboration invitation recipient may respond as follows:

Accept request for collaboration
Delegate request for collaboration to another participant
Reject request for collaboration

Preconditions	Collaboration invitation has been initiated by an activated member of the care team and received in the form of a secure message containing a unique invitation token.
Inputs	Invitation Token Response Type (Accept, Reject, Delegate) Invitation recipient Role and Person/Entity Details [if response type is delegation] New Collaborator Role and Person/Entity Details
Outputs	none
Postconditions	Invited participant becomes a new member of the care team with access to patient care context.
Exception Conditions	Invitation has been recalled by placer Invitation has expired due to inaction Invitation can not be delegated
Included in Profiles	edit here
Outstanding Issues	edit here

Find All Collaboration Participant Relationships

Capability Status	2-26-2012	Proposed	Reviewers Here

Collaboration participant relationships represent a mini-community of individuals working towards the patient's health goals. The relationships are a network or social graph used to support collaboration in care coordination activities. This capability supports awareness of the patient's circle of care and the relationships between individuals.

These relationships grow organically as the care team sends invitations to collaborate on care coordination activities. For example, an invitation from a licensed independent practitioner (LIP) to a cardiologist results in two new relationship links from the new provider to the patient and between the existing and new providers.

Preconditions	none
Inputs	Patient role and Person information
Outputs	Persons, the roles they are playing and links based on their role relationships.
Postconditions	none
Exception Conditions	none
Included in Profiles	edit here
Outstanding Issues	edit here

Care Collaboration - Team Conversation Capability Set

Care Team Chat Conversation Thread

Capability Status	2-26-2012	Proposed	Reviewers Here

Conversation is the heart of collaboration. Any member of the care team may initiate a conversation with a different member of the care team at any time. By default the conversation is private to the participants involved. Organizational policies and business rules engines may determine if a conversation is visible beyond the direct participants (as a principle CCS delegates to external policy checks).

The CCS conversation model captures both the free form text content of business interactions but it can also link to the semantic structured context pertaining to the conversation.

A conversation may simply consist of free text such as a questions from a patient to his or her provider. A conversation may also pertain to a some aspect of the care plan such as: a communication about a specific health goal, health concern, health risk, intervention outcome, associated plan and goal reviews or some diagnostic observation about the patient. The semantic links put the conversation in context.

Conversations will naturally form threads containing multiple communications about some topic.

Care team communications may also have optional multimedia support (attached photograph of video clip)

Preconditions	The receiving individual is in an active care team member for the associated patient.
Inputs	Patient Scoping care plan, plan of care or treatment plan Communication free form text content Link to structured semantic context (e.g. Plan, HealthGoal, HealthConcern, Outcomes, Team Member, Reviews, ...)
Outputs	none
Postconditions	none
Exception Conditions	none
Included in Profiles	edit here
Outstanding Issues	Identify specific classes from care plan analysis model

Invite New Conversation Participants

Capability Status	2-26-2012	Proposed	Reviewers Here

An invitation may be sent by a conversation participant to a member who was not involved in the original thread. The invitation enables the new participant to follow the existing conversation thread and also respond to specific communication entries.

Preconditions	Invitation placer must be a participant in the existing conversation. New conversation participant must already be a member of the care team
Inputs	Link to existing conversation Role and Person details of the invitation placer Role and Person details of invited participant(s)
Outputs	none
Postconditions	New collaborator receives a secure message with request to join existing conversation
Exception Conditions	none
Included in Profiles	edit here
Outstanding Issues	edit here

Respond to Conversation Invitation

Capability Status	2-26-2012	Proposed	Reviewers Here

A conversation invitation recipient may respond as follows:

Accept to join conversation
Delegate conversation request
Reject conversation request

Preconditions	There is a pending invitation to join a conversation
Inputs	Invitation Token Response Type (Accept, Reject, Delegate) Invitation recipient Role and Person/Entity Details [if response type is delegation] Delegated participant Role and Person details
Outputs	none
Postconditions	edit here
Exception Conditions	edit here
Included in Profiles	edit here
Outstanding Issues	edit here

Find All Conversation Participants

Capability Status	2-26-2012	Proposed	Reviewers Here

This capability identifies participants involved in a specific conversation thread.

Preconditions	none
Inputs	Patient role and Person information
Outputs	Persons, the roles they are playing and links based on their role relationships.
Postconditions	none
Exception Conditions	none
Included in Profiles	edit here
Outstanding Issues	edit here

Care Collaboration - Participant Availability Capability Set