Care Coordination Capabilities

Return to: Care Coordination Service

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 exchanged as CDA documents or sections therein, but there is no standard structure or service that unifies them or directly supports the collaboration, reconciliation, consolidation, and 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,for some selected plan items, or for the plan 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.

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".

The Care Coordination Service (CCS) capabilities comprise the core of the normative content of the HL7 SOA Service Functional Model (SFM) based on the Health Services Specification Program (HSSP) methodology.

These capabilities naturally fall into logical groupings which we'll also represent as UML interfaces in the informative part of the HL7 SOA SFM. The logical groupings will be referred to as capability sets in this document.

As a rule the capabilities are independent from organizational policies and business rules. This decoupling allows 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 HL7 CCS service functional model (SFM) specifies business service capabilities to support collaboration on care coordination activities. These business service capabilities are intentionally expressed in terms of the HL7 patient care domain analysis models. A follow up effort by this group in collaboration with OMG will focus on the development of a technical specification which will define services, messages and network communications interactions.

Complementary Efforts

• HL7 Care Plan Initiative

• LCC Longitudinal Care Plan (LCP) SWG

Care Collaboration - Care Team 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 a collaborator in care coordination activities for one patient. Participants join the the Care Team via an invitation based process which results in organically growing the patient's care team. Instead of making a phone call and sending faxes a licensed independent practitioner, a nurse or a physician, would send an invitation to collaborate. This invitation is the first step to initiate interactions with new care team members for referrals, transitions of care, consultations, etc.

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

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

Policies and rules regarding who is entitled to send and receive invitations for collaboration and the corresponding level of visibility into patient care activities 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	Role and Person details for initiating collaborator Patient details New collaborator Role and Person details Collaboration Reason (e.g referral, care transition) Link to Care Plan, Plan of Care
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	Discuss role of treatment plan

Respond to Collaboration Invitation

Capability Status

2-26-2012

Proposed

Reviewers Here

An invitation response results in the addition of a new care team participant upon acceptance. The recipient of the invitation may also reject the invitation or delegate to a colleague.

Allowed response types are:

• Accept request for collaboration
• Delegate request for collaboration to another participant
• Delegate request but choose to stay in the collaboration loop (e.g. supervising provider)
• Reject request for collaboration

Preconditions	A collaboration invitation has been initiated by an active 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_Completely, Accept_And_Delegate) Invitation recipient Role and Person details [if response type is delegation] New Collaborator Role and Person 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 Collaborator Relationships

Capability Status

2-26-2012

Proposed

Reviewers Here

Care coordinators are collaborators working towards the patient's health goals and execution of care plan and plans of care. Their relationships form a social graph used to support collaboration in care coordination activities. This capability supports awareness of the patient's circle of care for all participants of the care team and is the foundation for effective and meaningful communications to support transitions, follow up, closing the loop, etc. This capability helps to identify who is involved and what their role in care is.

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.

Note: The contents of social graph may be filtered based on policies and business rules. For example, it may not be desirable for certain team members to discover that a patient is seeing a mental health provider.

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 - Care Team Conversation Capability Set

Care Team 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 another member of the care team at any time in order to coordinate care. By default the conversation is private to the participants involved. Organizational policies and business rules may determine if a conversation is visible beyond the direct participants.

The CCS conversation model:

• Captures the free form text, natural language, content of business interactions
• May capture structured observations resulting from question/answer electronic form interactions.
• Links to the semantic structured context pertaining to the conversation (clinical statements)

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

As a default conversations are private to the original participants. The invitation concept allows new participants to join the conversation.

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

An invitation response results in the addition of a new participant to the conversation thread upon their acceptance. The recipient of the invitation may also reject the invitation or delegate to a colleague.

Allowed response types are:

• Accept to join conversation
• Delegate to a different participant
• Delegate request but choose to stay in the conversation loop
• Reject to join conversation

Preconditions	There is a pending invitation to join a conversation
Inputs	Invitation Token Response Type (Accept, Reject, Delegate, Accept_And_Delegate) Invitation recipient Role and Person Details [if response type is delegation] Delegated participant Role and Person details
Outputs	none
Postconditions	edit here
Exception Conditions	Delegated individual not entitled for conversation visibility
Included in Profiles	edit here
Outstanding Issues	edit here

Identity Conversation Thread Participants

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability supports identification of participants involved in a specific conversation thread and their relationships.

Preconditions	none
Inputs	Patient role and Person information Plan identifier Conversation thread identifier
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

Participant availability the care team's virtual presence for involvement in collaborative interactions to support care coordination activities.

Participants control their online or offline virtual presence as a way to indicate their availability to other members of the care team.

Online indicates that the individual is available. Possible values are:

• Available for all
• Available but away from computers (e.g. don't expect a reply
• Do not disturb - unless critical
• Do not disturb - unless message pertains to a specific patient identified by the provider
  • e.g. don't bother me during office visits unless it pertains to the patient I am meeting

Offline indicates that the individual is not available for any interactions with his or her care team.

Indicate Personal Availability for Collaboration

Capability Status

2-26-2012

Proposed

Reviewers Here

Care coordination participants indicate their availability in order to facilitate conversations with collaborating care team members. Availability may include work hours supplemented with online/offline preferences.

Preconditions	none
Inputs	Role and Person information setting his or her Availability Availability, work schedule Indication of online/offline preferences
Outputs	none
Postconditions	none
Exception Conditions	edit here
Included in Profiles	edit here
Outstanding Issues	edit here

Find Collaborator Availability

Capability Status

2-26-2012

Proposed

Reviewers Here

Care team members may query the availability of other care team members to discover times when joint care coordination conversations may occur.

Preconditions	Requester must share a care team with the individual whose availability is being requested
Inputs	Role and Person information for individual whose availability is being requested
Outputs	Availability
Postconditions	none
Exception Conditions	none
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

Patient Observations Capability Set

This capability set supports capture and querying of patient observations. Observations may be made at any stage of the care process.

For example:

• Subjective and objective observations are made in support of the assessment and screening processes.
• Observations capture intervention outcomes
• Observations capture results of forms questionnaires
• Observations capture results of assessment scales and instruments

Some example observation types include:

• Problems
• History (social, family)
• Diagnostic Study Results (lab, radiology)
• Therapeutic Procedure/intervention
• H&P - History and Physical Exam
• Assessment
• Risk

Capture Patient Observations

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability supports capturing of observations. This may include either a single observation or a group of related observations.

Preconditions	none
Inputs	New Observation or ObservationGroup The Observation Type can be: QualitativeObservation Measurement NaturalLanguageObservation
Outputs	none
Postconditions	none
Exception Conditions	Observations made out of range
Included in Profiles	edit here
Outstanding Issues	edit here

Associate Observations

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability supports association of related observations. For example, a diagnosis may be associated with the observations which lead to the diagnosis. In this case, the diagnosis observation would be an interpretation of one or more observations.

Preconditions	none
Inputs	Source observation Target observation Association Type (e.g. interpretation, evaluation, cause)
Outputs	none
Postconditions	none
Exception Conditions	Inconsistent association (e.g if source and target were reversed when associating a diagnosis with its supporting observations)
Included in Profiles	edit here
Outstanding Issues	Identify enumeration of association types Provide some examples

Edit Observations

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability supports changing the values of an existing Observation or ObservationGroup.

Preconditions	none
Inputs	Existing Observation or ObservationGroup New Observation or ObservationGroup
Outputs	none
Postconditions	none
Exception Conditions	none
Included in Profiles	edit here
Outstanding Issues	edit here

Retrieve Observations

Capability Status

2-26-2012

Proposed

Reviewers Here

The retrieve observations capability supports query of patient observations based on time frame and type filters.

Example uses:

• Retrieve patient's problems
• Retrieve patient's family history observations
• Retrieve patient's social history observations
• Retrieve patient's diagnostic results
• Retrieve patient's vital signs

Preconditions	edit here
Inputs	Patient Date Range Encounter Identifier Observation Type Code Problems History (social, family) Diagnostic Study Results Therapeutic Procedure/intervention H&P History and Physical Exam Assessment Risk etc...
Outputs	edit here
Postconditions	edit here
Exception Conditions	edit here
Included in Profiles	edit here
Outstanding Issues	Get more requirements

Identify Health Assessment Scales

Assessment Scale: A measurement instrument used to evaluate the health status of a person (e.g. quantitative, qualitative and psychometric assessment scales).

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability identifies assessment scales to use as part of an observational PlanAction.

Note: The HL7 Patient Care Workgroup Assessment Scales topic was balloted as DSTU on December 2012. More information here: http://wiki.hl7.org/index.php?title=Assessment_Scales

Preconditions	none
Inputs	Assessment scale identifier
Outputs	none
Postconditions	none
Exception Conditions	none
Included in Profiles	edit here
Outstanding Issues	edit here

Care Planning - Plan Life Cycle Capability Set

Establish Plan (Care Plan, Plan of Care or Treatment Plan)

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability establishes a new plan for the patient. The plan must be one of the following:

• Care Plan
• Plan of Care
• Treatment Plan

Preconditions	none
Inputs	Patient who is the subject of the plan Plan Type (CarePlan, PlanOfCare, TreatmentPlan) Licensed independent practitioner (LIP) responsible for the CarePlan, PlanOfCare or TreatmentPlan Steward organization Additional care team participants if known (Provider, CareGiver, SupportingMember) Plan details and optional HealthConcern(s), HealthGoal(s), HealthRisk(s), CareBarriers, ProposedAction(s)
Outputs	none
Postconditions	edit here
Exception Conditions	edit here
Included in Profiles	edit here
Outstanding Issues	edit here

Revise Plan

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 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 health concerns, goals and risks, and planned actions, ask whether planned actions are appropriate

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions	Clinical Decision Support System (CDSS) is utilized in the implementation of a CSS collaborative participant.
Inputs	Some combination of health concerns, goals and risks, and planned actions have been specified as discussion context. This establishes the scope of the analysis to be performed.
Outputs	CDS advice is provided in the form of communications within the discussion.
Postconditions	If the CDS advice includes suggestions to add, remove, or modify goals or planned actions, then proposed changes have been attached to the thread (for review and acceptance)
Exception Conditions	If the request activates CDS rules that require additional data, then a notice to that effect is given in the discussion thread, and the implementation may prompt for the required data elements.
Included in Profiles	edit here
Outstanding Issues	JF see phoenix notes and flesh this out

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

Progress Tracking

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

Allocate Resources

• 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

Allocate Resources

• 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 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 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 Status

2-26-2012

Proposed

Reviewers Here

Do we still have an appropriate target for these actions that are being undertaken?

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 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

Consolidation/Reconciliation Capability Set

These capabilities operate on multiple plans that are present in the same workspace.

Consolidate Plans Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

Produce a plan that is the superset of all plan items from the specified original plans.

Unlike the reconciliation capability, this capability actually creates a new resulting plan. As a safety precaution, the consolidation function does not overwrite any of its sources. The new plan may, as a separate operation, be made to overwrite one of the source plans.

Preconditions	Two or more plans have been included in the working set
Inputs	Reference to a working set that contains to two or more plans (the plans need not be structured yet) Multi-level Override option (to allow consolidation even of plans at multiple levels). If this is not set then the server will consolidate items only of the same level (CPs with CPs, POCs with POCs, TPs with TPs)
Outputs	Reference to the newly created plan
Postconditions	A new plan has been created (but not activated). The original plans are not affected. The content of the new plan is the union of all plan items of the original plans.
Exception Conditions	Specified plans must be of same level (care plan, plan of care, or treatment plan) but override was not requested
Part of Profiles
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

Get Reconciliation Work List Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

Given a set of plans or plan items, sort the items by item type (e.g. problems, interventions) and flag those item sets that are suspected as being redundant. This resulting structure could then be the basis for letting the user select the items to remove or to generate proposed removals.

The plans or plan items of concern could be at different levels or at the same level. For example, two "plans of care" are including medication for the same period for the same condition. As another example, a "care plan" and a "plan of care" show the same type of redundancy, but the POC has not been included under the CP.

Note that the CCS server, in order to avoid "false negatives" (falsely concluding that items are not redundant), must utilize terminology assets in order to detect whether an item A "covers" item B even if their concept codes are different (for example Tylenol and Acetaminophen are equivalent and hence to be suspected as redundant)

Preconditions	Plans of interest are in the working set, even if POCs are not yet linked under PCs
Inputs	Selections of the content to be considered (plan items or entire plans)
Outputs	An ordered collection of Sets of plan items (goals, barriers, interventions, etc.) with flags on items suspected as being redundant. For example, if the input plan items consisted of problems and goals, then the output would contain two major sets (problems and goals) with each major set listing nonredundant items of its type as well as "redundancy" groups for its type. In a "problems and medications" reconciliation, the medications major group might look like the following Medications: (major group) Ibuprofen (from POC a) Redundant Group 1 Tylenol (from POC b) Acetaminophen (from POC a) Accolate (from POC b)
Postconditions	no effects (the reconciliation work list is delivered as output, but it is not presumed to be stored)
Exception Conditions	None
Included in Profiles	edit here
Outstanding Issues	Should this operation "provide the option" to generate proposed item removals? How would it know which items are the keepers. Perhaps at the workspace level the user (the client app) can set precedence rules (the "pecking order" to control what carries). To Do: See HL7 Medication Statement Service (MSS) Profile, balloted in Sep 2012 for DSTU. The CCS output for this capability will be aligned with the MSS structure, but generalized so that reconciliation worksheets for other plan structures (e.g. problems) are supported.

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) Please specify as a subsection of a logical capability set grouping
Description	[Mandatory] High-level [functional] description of the expected behavior Please document as free form paragraph after capability title header
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