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Care Coordination Capabilities

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Contents

Business Purpose of the Specification

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

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

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

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

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

Business Capabilities

What are capabilities

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

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

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

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

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

The road ahead:

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

The Problem

CCS Solution Overview

Complementary Efforts

Care Collaboration - Build "Social" Network Capability Set

Invite to Collaboration Participants

Capability Status

2-26-2012

Proposed

Reviewers Here

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

  • A patient can directly invite providers and care givers to join his or her care team (as the patient is the first member of the care team).
  • An invitations may be sent from an any existing care team participant to new care team member.
  • The patient's delegated steward of their care plan, licensed independent practitioner (LIP) (e.g. PCP or other professional care plan facilitators such as a nurse case manager) will typically serve as the "seed" of the collaboration tree as they invite other providers to collaborate in care coordination.

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

Precondition

The invitation placer must be an existing member of the patient's care team. This may include the following roles as defined in the HL7 Care Plan model:

  • Patient
  • Provider
  • Care Giver
  • Support Member

Inputs

  • Initiating collaborator (Role and Person/Entity details)
  • Patient
  • New Collaborator (Role and Person/Entity details)
  • Collaboration Reason (e.g referral, care transition)

Outputs

none

Postconditions

New collaborator receives a secure message with request for collaboration

Exception Conditions

New collaborator not vetted by external policy checks

Included in Profiles

edit here

Outstanding Issues

edit here

Respond to Collaboration Invitation

Capability Status

2-26-2012

Proposed

Reviewers Here

A collaboration invitation recipient may respond as follows:

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


Preconditions

Collaboration invitation has been initiated by an activated member of the care team and received in the form of a secure message containing a unique invitation token.

Inputs

  • Invitation Token
  • Response Type (Accept, Reject, Delegate)
  • Invitation recipient Role and Person/Entity Details
  • [if response type is delegation] New Collaborator Role and Person/Entity Details

Outputs

none

Postconditions

Invited participant becomes a new member of the care team with access to patient care context.

Exception Conditions

  • Invitation has been recalled by placer
  • Invitation has expired due to inaction
  • Invitation can not be delegated

Included in Profiles

edit here

Outstanding Issues

edit here

Find All Collaboration Participant Relationships

Capability Status

2-26-2012

Proposed

Reviewers Here

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

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

Preconditions

none

Inputs

Patient role and Person information

Outputs

Persons, the roles they are playing and links based on their role relationships.

Postconditions

none

Exception Conditions

none

Included in Profiles

edit here

Outstanding Issues

edit here

Care Collaboration - Team Conversation Capability Set

Care Team Chat Conversation Thread

Capability Status

2-26-2012

Proposed

Reviewers Here

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

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

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

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

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


Preconditions

The receiving individual is in an active care team member for the associated patient.

Inputs

  • Patient
  • Scoping care plan, plan of care or treatment plan
  • Communication free form text content
  • Link to structured semantic context (e.g. Plan, HealthGoal, HealthConcern, Outcomes, Team Member, Reviews, ...)

Outputs

none

Postconditions

none

Exception Conditions

none

Included in Profiles

edit here

Outstanding Issues

  • Identify specific classes from care plan analysis model

Invite New Conversation Participants

Capability Status

2-26-2012

Proposed

Reviewers Here

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

Preconditions

  • Invitation placer must be a participant in the existing conversation.
  • New conversation participant must already be a member of the care team

Inputs

  • Link to existing conversation
  • Role and Person details of the invitation placer
  • Role and Person details of invited participant(s)

Outputs

none

Postconditions

New collaborator receives a secure message with request to join existing conversation

Exception Conditions

none

Included in Profiles

edit here

Outstanding Issues

edit here

Respond to Conversation Invitation

Capability Status

2-26-2012

Proposed

Reviewers Here

A conversation invitation recipient may respond as follows:

  • Accept to join conversation
  • Delegate conversation request
  • Reject conversation request


Preconditions

There is a pending invitation to join a conversation

Inputs

  • Invitation Token
  • Response Type (Accept, Reject, Delegate)
  • Invitation recipient Role and Person/Entity Details
  • [if response type is delegation] Delegated participant Role and Person details

Outputs

none

Postconditions

edit here

Exception Conditions

edit here

Included in Profiles

edit here

Outstanding Issues

edit here

Find All Conversation Participants

Capability Status

2-26-2012

Proposed

Reviewers Here

This capability identifies participants involved in a specific conversation thread.

Preconditions

none

Inputs

Patient role and Person information

Outputs

Persons, the roles they are playing and links based on their role relationships.

Postconditions

none

Exception Conditions

none

Included in Profiles

edit here

Outstanding Issues

edit here

Care Collaboration - Participant Availability Capability Set

Indicate Personal Availability for Collaboration

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

edit here

Inputs

edit here

Outputs

edit here

Postconditions

edit here

Exception Conditions

edit here

Included in Profiles

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Outstanding Issues

edit here

Find Participant Availability for Collaboration

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

edit here

Inputs

edit here

Outputs

edit here

Postconditions

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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

edit here

Inputs

edit here

Outputs

edit here

Postconditions

edit here

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

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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Capture Causative or Interpretative Observation Links

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

edit here

Inputs

edit here

Outputs

edit here

Postconditions

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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

edit here

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

edit here

Inputs

edit here

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

edit here

Inputs

edit here

Outputs

edit here

Postconditions

edit here

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

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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Retire Plan Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

edit here

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

edit here

Inputs

edit here

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

edit here

Inputs

edit here

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

edit here

Inputs

edit here

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

edit here

Inputs

edit here

Outputs

edit here

Postconditions

edit here

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

edit here

Inputs

edit here

Outputs

edit here

Postconditions

edit here

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

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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Activity Outcome Review Capability

Capability Status

2-26-2012

Proposed

Reviewers Here

<<Insert Capability Description Here>>

Preconditions

edit here

Inputs

edit here

Outputs

edit here

Postconditions

edit here

Exception Conditions

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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

edit here

Inputs

edit here

Outputs

edit here

Postconditions

edit here

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

edit here

Inputs

edit here

Outputs

edit here

Postconditions

edit here

Exception Conditions

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Included in Profiles

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Outstanding Issues

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Cross-Plan Reconciliation Capability Set

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 to 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.

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

edit here

Included in Profiles

edit here

Outstanding Issues

See medication reconciliation standard; generalize its structure for other plan item types (e.g. problems).

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