Care Coordination Capabilities
Contents
- 1 Business Capabilities
- 2 Care Collaboration - Build "Social" Network Capability Set
- 3 Care Collaboration - Team Conversation Capability Set
- 4 Care Collaboration - Participant Availability Capability Set
- 5 Care Collaboration - Semantic Tagging Capability
- 6 Care Observations and Assessment Capability Set
- 7 Care Planning - Plan Life Cycle Capability Set
- 8 Clinical Evaluation of Plan Items
- 9 Recommend Plan Template Capability
- 10 Care Plan Implementation Capability Set
- 11 Care Review Capability Set
- 12 Documentation Template for Capability Details
Business 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.
Capabilities may be aggregated into logical groupings which may map to interfaces but they will simply be represented here as logical capability sets.
The Care Coordination capabilities comprise the core of the normative content specified by the CCS HSSP Service Functional Model 2.
As a general rule the capabilities are independent from organizational policies and business rules. This decoupling will allow capabilities to be combined to support various business processes and organizational policies.
Care Collaboration - Build "Social" Network Capability Set
Invite to Collaborate Capability
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:
|
Inputs |
|
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 |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Find All Collaboration Participants
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Care Collaboration - Team Conversation Capability Set
Care Team Chat Communications
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
TODO: Care team chat communications with optional multimedia support.
Preconditions |
edit here |
Inputs |
Free form text with linked semantic content
|
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Invite New Conversation Participants
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Respond to Conversation Invitation
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
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 |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Care Collaboration - Participant Availability Capability Set
Indicate Personal Availability for Collaboration
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Find Participant Availability for Collaboration
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Care Collaboration - Semantic Tagging Capability
Tag Collaborative Content
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Care Observations and Assessment Capability Set
Capture Subjective and Objective Patient Observations
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Capture Causative or Interpretative Observation Links
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Replace Prior Observations
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Specify Assessment Scales to Guide Observation Process
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Care Planning - Plan Life Cycle Capability Set
Establish Plan Capability
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Revise Plan Capability
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Retire Plan Capability
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Clinical Evaluation of Plan Items
Check Clinical Appropriateness Capability
Given a health concerns, goals and risks and existing plan actions are the interventions appropriate
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Recommend Plan Template Capability
Given a health concerns, goals and risks and barriers recommend a Plan template
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Care Plan Implementation Capability Set
Track Execution Status Capability
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Request Resource Allocation Capability
- Human Resources, Rooms, and Materials
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Request Service Allocation Capability
Assign Resource Capability
- Human Resources, Rooms, and Materials
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Care Review Capability Set
Acceptance Review Capability
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Activity Outcome Review Capability
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Goal Review Capability
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Plan Review Capability
Capability Status |
2-26-2012 |
Proposed |
Reviewers Here |
<<Insert Capability Description Here>>
Preconditions |
edit here |
Inputs |
edit here |
Outputs |
edit here |
Postconditions |
edit here |
Exception Conditions |
edit here |
Included in Profiles |
edit here |
Outstanding Issues |
edit here |
Documentation Template for Capability Details
The following template captures the level of detail required for the HL7 SOA HSSP Service Functional Model specification. The details make up section 5 of of the SFM boiler plate template which captures the "Detailed Functional Model for each Interface".
Please include at a minimum the mandatory fields when describing new capabilities.
Capability Status |
2-26-2012 |
Proposed |
Link of reviewers doodle poll when approved |
Name |
[Mandatory] A business-friendly name describing the context of the motivating scenario, and is unique within this Functional Model (e.g., “Find a Person” vs. FindPerson)
|
Description |
[Mandatory] High-level [functional] description of the expected behavior
|
Preconditions |
[Mandatory] Business Pre-conditions [may be null], i.e. what conditions must have been satisfied before the action can be requested or carried out |
Inputs |
[Mandatory] Inputs [include both mandatory and optional] |
Outputs |
[Mandatory] Outputs [include both mandatory and optional] |
Postconditions |
[Optional] Business Post-conditions, i.e. what conditions will result from the action being carried out. |
Exception Conditions |
[Mandatory] Business Exception Conditions [may be null] |
Part of Profiles |
[Optional] Specify service functional profiles which include the capability. Please specify if it is required or optional for profile conformance.
|
Aspects Left to OMG to Specify |
[Optional] Enumeration of aspects left to the technical specification [may be null] |
Outstanding Issues |
[Optional]If no issues but expect some while the capability is being worked out by the team |