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=<span style="color:blue">Business Purpose of the Specification</span>=
 
=<span style="color:blue">Business Purpose of the Specification</span>=
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).  
+
Presently in the Health Care industry, a patient may be under sequential or concurrent treatment by numerous and diverse care teams (e.g. the primary care clinic, home care, allied health professionals, hospital, skilled nursing facility, etc.), each of which maintains a “plan of care” that suits their perspectives, purposes, and time horizons.  Without a mechanism to contain and coordinate these plans, gaps and overlaps occur leading to compromised care and increased costs. 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 teamThe 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” or "treatment plans" may be exchanged as CDA documents (or sections therein); However, there is no standard structure or service that directly supports the "collaborative consolidation and harmonization" of those plans of care.   
  
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.
+
The CCS directly addresses these needs by building an invitation-based controlled discussion framework around a truly "shared" care plan structure.  This care plan carries past and present plans of care, yet keeps the long-term goals and treatments in view. The care team composition can be dynamically managed, and specific members may be called upon for pertinent discussions.  If "invited", even a Clinical Decision Support System may participate in discussions as a participant.  For example, it may raise concerns such as contraindications or unforeseen drug interactions comprehending "all" the currently active plans of care.
  
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.
+
In summary, the CCS will greatly support care management professionals by allowing them to organize the otherwise disjoint plans of care and treatment plans into a living and shared care plan, dramatically simplifying information flows for the care of a patient.
 
 
The CCS should allow for greatly increased manageability of care plans.
 
  
 
=<span style="color:blue">Overview of Coordination of Care Capabilities</span>=
 
=<span style="color:blue">Overview of Coordination of Care Capabilities</span>=

Revision as of 14:11, 14 March 2013


Return to: Care Coordination Service

Contents

Business Purpose of the Specification

Presently in the Health Care industry, a patient may be under sequential or concurrent treatment by numerous and diverse care teams (e.g. the primary care clinic, home care, allied health professionals, hospital, skilled nursing facility, etc.), each of which maintains a “plan of care” that suits their perspectives, purposes, and time horizons. Without a mechanism to contain and coordinate these plans, gaps and overlaps occur leading to compromised care and increased costs. These stakes are especially high in cases of chronic conditions (or multiple chronic conditions, such as Diabetes plus Cardiovascular disease).

There exist standards from HL7 and IHE by which specialty or episodic “plans of care” or "treatment plans" may be exchanged as CDA documents (or sections therein); However, there is no standard structure or service that directly supports the "collaborative consolidation and harmonization" of those plans of care.

The CCS directly addresses these needs by building an invitation-based controlled discussion framework around a truly "shared" care plan structure. This care plan carries past and present plans of care, yet keeps the long-term goals and treatments in view. The care team composition can be dynamically managed, and specific members may be called upon for pertinent discussions. If "invited", even a Clinical Decision Support System may participate in discussions as a participant. For example, it may raise concerns such as contraindications or unforeseen drug interactions comprehending "all" the currently active plans of care.

In summary, the CCS will greatly support care management professionals by allowing them to organize the otherwise disjoint plans of care and treatment plans into a living and shared care plan, dramatically simplifying information flows for the care of a patient.

Overview of Coordination of Care Capabilities

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.

Model Dependencies

Plan Capability Set

Find Plan Template

Capability Status

2-26-2012

Proposed

Reviewers Here


Definition: A plan template consists of predefined plan elements which are commonly included when addressing one or more health concerns based on research, clinical evidence or best practices. For example, there could be a plan template to treat patients with diabetes mellitus and cardiovascular disease.

This capability seeks a recommendation for applicable plan templates given the patient's health concerns, health goals, health risks and care barriers.


Preconditions

At a minimum, HealthConcern(s) are identified

Inputs

  • HealthConcern(s) [required]
  • HealthGoal(s) [optional]
  • HealthRisk(s) [optional]
  • CareBarrier(s) [optional]

Outputs

A CarePlan, PlanOfCare or TreatmentPlan

Postconditions

none

Exception Conditions

none

Included in Profiles

edit here

Outstanding Issues

Resolve context which determines how the result plan type is determined (CarePlan, PlanOfCare or TreatmentPlan)

Find Plan

Capability Status

2-26-2012

Proposed

Reviewers Here

<<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

Create Plan

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability establishes a new plan for the patient. A plan can be either a Care Plan, a Plan of Care or a Treatment Plan as defined in the HL7 Patient Care workgroup's Care Plan domain analysis model.

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

Edit Plan

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability supports editing of the intrinsic "plan" attributes.


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

Close Plan

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability marks the plan as inactive.

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

Read Plan

Capability Status

2-26-2012

Proposed

Reviewers Here

<<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

Share Plan

Capability Status

2-26-2012

Proposed

Reviewers Here

<<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

Synchronize Plan

Capability Status

2-26-2012

Proposed

Reviewers Here

<<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

Manage Supportive Plan Content Capability Set

Link Supportive Content

Capability Status

2-26-2012

Proposed

Reviewers Here

The majority of plan items contained in plans of care and treatment plans will have no continuing relevance after the plan is closed. However, there will be some items - whether from closed care plans or from the health record - that will stay important for future planning. For example, a kidney transplant procedure note would stay relevant to care planning for the life of the patient. A duly authorized user should be able to link (or unlink) supportive content to the a plan. Any supportive content linked to the care plan level can then be made easily accessible by the UI of a CS-enabled client application (subject to access controls). However, any supportive content linked to a lower-level (plan of care or treatment plan) will "fall off" the care plan as soon as the plan of care is closed.

In some cases the content item can be linked via a URL, while in other cases it cannot. Therefore this operation permits links that are not machine processible.

A CCS-enabled client application would make these links to supportive content easily accessible and hard to miss.

Preconditions

There exists some content from the health record or from a closed plan that is of lasting relevance to care planning.

Inputs

  • Plan Identifier of the plan to which content is to be linked.
  • Title (to be used in a compact list of the care plan's supportive items)
  • Estimated or Actual clinical effective date of the item
  • (Optional) URI or URL of the supportive content
  • (Optional) comments

Outputs

None

Postconditions

The item is linked to the care plan as supportive content.

Exception Conditions

None

Included in Profiles

edit here

Outstanding Issues

None

Unlink Supportive Content

Mark Plan Items for Action Capability Set

These capabilities allow care team members to organize plan items into groups in support of discussions and actions.

For example:

  • To specify a set of conflicting goals that need to be discussed
  • To designate two plans to merge
  • To specify plan items requiring review or comment

Many operations can be performed on groups of plan items.

Tag Plan Item

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

edit here

Inputs

edit here

Outputs

edit here

Postconditions

none

Exception Conditions

none

Included in Profiles

edit here

Outstanding Issues

edit here

Retrieve Tag Group

Capability Status

2-26-2012

Proposed

Reviewers Here

Retrieve plan item set based on tag names.

Preconditions

none

Inputs

  • Patient
  • Plan identifier [optional]
  • Tag Name
  • Include historical

Outputs

Plan Item Set

Postconditions

none

Exception Conditions

none

Included in Profiles

edit here

Outstanding Issues

edit here

Care Collaboration - Care Team Capability Set

Find Person

Invite 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

Add Care Team Member

Capability Status

2-26-2012

Proposed

Reviewers Here

<<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

Remove Care Team Member

Capability Status

2-26-2012

Proposed

Reviewers Here

<<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 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, Medications, Allergies, any PlanItemSet, etc.)

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

Identify 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 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

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

Clinical Appropriateness Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability determines whether a planned action is appropriate given health concerns, health goals, health risks, and existing planned actions.

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

Care Plan Action Capability Set

Mark Start

Minimally this capability records that a specified planned action is started. Optionally, the process is made to actually start, perhaps triggering an HL7 interaction.

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

Mark Suspend

This capability starts the specified planned action - by whatever means are available to the implmentation

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

Mark Resume

This capability starts the specified planned action - by whatever means are available to the implmentation

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

Mark Cancel

This capability starts the specified planned action - by whatever means are available to the implmentation

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

Mark Complete

This capability starts the specified planned action - by whatever means are available to the implmentation

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

Monitor Status

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

Set Execution Status

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

edit here

Inputs

edit here

Outputs

edit here

Postconditions

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Exception Conditions

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Included in Profiles

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Outstanding Issues

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Allocate Resources

  • 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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Allocate Resources

  • 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 Status

2-26-2012

Proposed

Reviewers Here

Acceptance reviews capture understanding and agreement to adopt a proposal for health goals, interventional actions or the plan itself. E.g. Upon review of the goals and planed actions a care manager (e.g. nurse case manager, social worker, physical therapist, pharmacist), PCP, nurse and patient will indicate understanding and acceptance of the Care Plan. Acceptance reviews may be used to indicate a provider’s authorization to perform an intervention and another’s provider acknowledgement.


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 Status

2-26-2012

Proposed

Reviewers Here

An action outcome review measures the result of individual implemented action (observational or interventional) against goal success criteria. The action outcome review might address only a subset of goal success criteria.


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 Status

2-26-2012

Proposed

Reviewers Here

Goal reviews reference multiple action outcomes reviews which support overall assessment of a HealthGoal.

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

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 Status

2-26-2012

Proposed

Reviewers Here

Plan reviews are performed at periodic intervals to assess the overall consistency, appropriateness, completeness and effectiveness of the plan. The plan review includes comprehensive review of all the goals.


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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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

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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