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Difference between revisions of "Care Coordination Capabilities"

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'''Precondition'''
 
'''Precondition'''
 
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The participant must either be:
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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:
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* The patient who holds ultimate authority in selecting his or her care team.
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* Patient
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* The patient's PCP
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* Provider
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* A participant who has received invitations from either the patient or PCP via a chain of trust reflected by pre-existing organizational policies
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* Care Giver
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* Support Member
 
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* Patient
 
* Patient
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* New Collaborator
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* New Collaborator (Role and Person/Entity details)
 
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Revision as of 19:31, 27 February 2013

Contents

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:

  • Patient
  • Provider
  • Care Giver
  • Support Member

Inputs

  • Patient
  • New Collaborator (Role and Person/Entity details)

Outputs

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Postconditions

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Exception Conditions

  • New collaborator not vetted by external policy checks

Included in Profiles

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Outstanding Issues

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Respond to Collaboration Invitation

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Find All Collaboration Participants

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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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

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Inputs

Free form text with linked semantic content

  • Communication
  • Semantic context (e.g. Plan, HealthGoal, HealthConcern, Outcomes, Team Member)

Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Invite New Conversation Participants

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Respond to Conversation Invitation

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Find All Conversation Participants

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Care Collaboration - Participant Availability Capability Set

Indicate Personal Availability for Collaboration

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Find Participant Availability for Collaboration

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Care Collaboration - Semantic Tagging Capability

Tag Collaborative Content

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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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

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Capture Causative or Interpretative Observation Links

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Replace Prior Observations

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Specify Assessment Scales to Guide Observation Process

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Care Planning - Plan Life Cycle Capability Set

Establish Plan Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Revise Plan Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Retire Plan Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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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

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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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

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Care Plan Implementation Capability Set

Track Execution Status Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Request Resource Allocation Capability

  • Human Resources, Rooms, and Materials

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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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

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Care Review Capability Set

Acceptance Review Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Activity Outcome Review Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Goal Review Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Plan Review Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

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Inputs

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Outputs

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Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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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

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