1. Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) June 26, 2013 1

2. Meeting Etiquette Remember: If you are not speaking, please keep your phone on mute Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call o Hold = Elevator Music = frustrated speakers and participants This meeting is being recorded o Another reason to keep your phone on mute when not speaking Use the Chat feature for questions, comments and items you would like the moderator or other participants to know. o Send comments to All Participants so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute All Participants

3. 3 For this initiative: Interoperable and shared patient assessments across multiple disciplines Shared patient and team goals and desired outcomes Care plans which align, support and inform care delivery regardless of setting or service provider For this Tiger Team: Alignment of HL7 artifacts with LCC artifacts to support care plan exchange HL7 CCS provides Service Oriented Architecture Care Plan DAM provides informational structure LCC Implementation Guides provide functional requirements Goals

4. Agenda Introductions Goals Schedule Discussion of Prioritizations –Ongoing comments can be submitted and viewed on wiki: http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG Next Steps 4

5. Schedule – June/July 2013 SUNDAYMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAY 2345678 11 AM ET: Discussion Prioritization 9101112131415 11 AM ET Meeting Canceled Tentative Presentation to HL7 (TBD) 16171819202122 11 AM ET HL7 Preference and Priority as shown in DAM 23242526272829 11 AM ET Discussion Connections, Crosswalks 30JULY 1JULY 2JULY 3JULY 4JULY 5JULY 6

6. Work Group Schedules LCC WG SWG MeetingLCC LeadsDate/ TimeProjects LTPAC SWGLarry Garber Terry O'Malley Weekly Mondays, 11-12pm EST C-CDA: Transfer Summary, Consult Note, Referral Note LCC HL7 Tiger Team Russ LeftwichWeekly Wednesdays, 11- 12pm EST LCC WG comments for HL7 Care Plan DAM LCP SWGBill Russell Sue Mitchell Jennie Harvell Weekly Thursdays 5-6pm EST C-CDA: Care Plan, HomeHealth Plan of Care HL7 WG SWG MeetingHL7 LeadParticipating LCC Members Date/ TimeProjects HL7 Patient Care WGRuss Leftwich Elaine Ayers Stephen Chu Michael Tan Kevin Coonan Susan Campbell Laura H Langford Lindsey Hoggle Bi-weekly Weds, 5 - 6pm EST Care Plan DAM Care Coordination Services (CSS) HL7 Structured Documents WG Bob Dolin Brett Marquard Sue Mitchell Jennie Harvell Weekly Thursdays, 10-12pm EST CDA (various) HL7 SOA WG CCS ProjectJon Farmer Enrique Meneses (facilitators) Stephen Chu Susan CampbellWeekly Tuesdays 5 - 6pm EST Care Coordination Services (CSS) HL7 Patient Generated Document Leslie Kelly HallWeekly Fridays, 12- 1pm EST Patient-authored Clinical Documents

7. 7 Associations between Care Team Members and Health Concerns/Goals/Interventions Is it sufficient to associate one or more Care Team Members with a data element or should the model include levels of association? If so, what is the value set for those role/relationship levels? How many levels should there be and how are they represented (e.g. primary/secondary,/tertiary, or lead/support, or other) Tiger Team Discussion Points

8. 8 Can team members be associated with an intervention but not associated with any health concerns/goals? Do association need to be separated out or do we assume that if a team member is associated with a health concern that theyre associated with an intervention and/or a goal? Can data elements (health concern/goal/intervention) be associated with zero care team members (other than the patient, who would be associated by default)? Current model includes Role attribute in Health Concern but not in Health Goal or Plan Activity (Intervention) Need to define and establish attributes for Plan Activity (Intervention) Tiger Team Discussion Points

9. 9 Care Plan DAM – Team Member View

10. 10 Care Plan DAM – Health Concern Includes expressed by role but no association role(s)

11. 11 Care Plan DAM – Goal Does not include any role(s) for expressed by or association

12. 12 Care Plan DAM – Plan Activity (Intervention) Does not currently include any attributesneed to define

13. 13 Questions/Comments to PCWG Is it sufficient to associate one or more Care Team Members with a data element or should the model include levels of association? If so, what is the value set for those role/relationship levels? How many levels should there be and how are they represented (e.g. primary/secondary,/tertiary, or lead/support, or other) Comment: These associations must be expressed as part of the model so it can trace back to whoever has responsibility assigned to the health concern, goal or intervention so they can get paid for it. Comment: Its critical to assign a team members role and responsibility. The model needs to support some kind of self-identification as well as the ability to tag another individual as being engaged.

14. 14 Questions/Comments to PCWG Can team members be associated with an intervention but not associated with any health concerns/goals? Do association need to be separated out or do we assume that if a team member is associated with a health concern that theyre associated with an intervention and/or a goal? Comment: Roles should be assigned at the intervention level with a relationship to the goal, but we dont need an explicit connection between the team member and the goal. The roles shouldnt be dependent on the health concern or who assigned the health concern.

15. 15 Questions/Comments to PCWG Can data elements (health concern/goal/intervention) be associated with zero care team members (other than the patient, who would be associated by default)? NOTE: No feedbacknot discussed during this session

16. 16 Questions/Comments to PCWG Current model includes Role attribute in Health Concern but not in Health Goal or Plan Activity. Comment: It would be helpful to establish a taxonomy to support how the association/relationship will be used (e.g., as a messaging filter to only send information to certain entities and/or showing who is involved and their sub-roles and/or other).

17. 17 Questions/Comments to PCWG Need to define and establish attributes for Plan Activity (Intervention) Recommendation: List attributes that can currently be defined and then, if feasible, list placeholders or blank space for attributes that need to be defined at a later time: Attribute 1: goalAssociation Attribute 2: TBD (goalRole, goalRelationship or other) NOTE: Additional attributes would be listed as placeholders so that the model can be flexible enough to continue to enable the standard, which will evolve with future needs. Recommendation: Add association attribute(s) to the Activity level data element (perhaps as part of +performer and +requester as they relate to Role component. Recommendation: Association should include both individual and organization under functional role in addition to level of association/relationship (who would see the information at any given time).

18. Proposed Next Steps Next Touch Point meeting with PCWG is TBD Update discussion schedule Finalize LCCs Comments by August 4, 2013 for submittal as part of September Ballot

19. 19 Contact Information Were here to help. Please contact us if you have questions, comments, or would like to join other projects. S&I Initiative Coordinator Evelyn Gallego evelyn.gallego@siframework.orgevelyn.gallego@siframework.org Sub Work Group Lead Russ Leftwich cmiotn@gmail.comcmiotn@gmail.com Program Management Lynette Elliott lynette.elliott@esacinc.comlynette.elliott@esacinc.com Becky Angeles becky.angeles@esacinc.combecky.angeles@esacinc.com

20. 20 Background Slides

21. 21 3.4Observation, Condition, Diagnosis, Concern NOTE: The HL7 Patient Care Technical Committee is developing a formal model for condition tracking. The examples provided here are greatly simplified so as to illustrate certain aspects of SNOMED CT implementation. Observations, Conditions, Diagnoses, and Concerns are often confused, but in fact have distinct definitions and patterns. "Observation" and "Condition": An HL7 observation is something noted and recorded as an isolated event, whereas an HL7 condition is an ongoing event. Symptoms and findings (also know as signs) are observations. The distinction between "seizure" and "epilepsy" or between "allergic reaction" and "allergy" is that the former is an observation, and the latter is a condition. SNOMED CT distinguishes between "Clinical Findings" and "Diseases", where a SNOMED CT disease is a kind of SNOMED CT clinical finding that is necessarily abnormal: [ 404684003 | Clinical finding ] [ 64572001 | Disease ] SNOMED IG Definitions Continued on next slide

22. 22 The SNOMED CT finding/disease distinction is orthogonal to the HL7 observation/condition distinction, thus a SNOMED CT finding or disease can be an HL7 observation or condition. "Diagnosis": The term "diagnosis" has many clinical and administrative meanings in healthcare A diagnosis is the result of a cognitive process whereby signs, symptoms, test results, and other relevant data are evaluated to determine the condition afflicting a patient. A diagnosis often directs administrative and clinical workflow, where for instance the assertion of an admission diagnosis establishes care paths, order sets, etc. A diagnosis is often something that is billed for in a clinical encounter. In such a scenario, an application typically has a defined context where the billable object gets entered. "Concern": A concern is something that a clinician is particularly interested in and wants to track. It has important patient management use cases (e.g. health records often present the problem list or list of concerns as a way of summarizing a patient's medical history). SNOMED IG Definitions, contd… Continued on next slide

23. 23 Differentiation of Observation, Condition, Diagnosis, and Concern in common patterns: "Observation" and "Condition": The distinction between an HL7 Observation and HL7 Condition is made by setting the Act.classCode to "OBS" or "COND", respectively. The distinction between a SNOMED finding and SNOMED disease is based on the location of the concept in the SNOMED CT hierarchy. There is no flag in a clinical statement instance for distinguishing between a SNOMED CT finding vs. disease. "Diagnosis": Result of a cognitive process: Could potentially be Indicated by post-coordinating a SNOMED CT finding method attribute with a procedure such as "cognitive process". Directs administrative and clinical workflow: These use cases typically rely more on the context in which the diagnoses are entered (e.g. where an order set has a field designated for the admission diagnosis). In such a case, the distinction of a (particular kind of) diagnosis is that it occurs within a particular organizer (e.g. a condition within an Admission Diagnosis section is an admission diagnosis from an administrative perspective). Something that is billed for: The fact that something was billed for would be expressed in another HL7 message. There is nothing in the pattern for a diagnosis that says whether or not it was or can be billed for. SNOMED IG Definitions, contd… Continued on next slide

24. 24 "Concern": The HL7 Patient Care Technical Committee is developing a formal model for condition tracking. In that model, a problem (which may be an Observation, a Procedure, or some other type of Act) is wrapped in an Act with a new Act.classCode CONCERN. The focus in this guide is on the use of SNOMED CT, whereas the Patient Care condition tracking model is the definitive source for the overall structure of a problem list. It should be noted that the administrative representation of a diagnosis and the representation of a concern break the rules from section 3.1.1 Observations vs. Organizers, in that these designations are based on context, whereas the designation of something as an Observation vs. Condition is inherent in the clinical statement itself. SNOMED IG Definitions, contd…

25. 25 HL7 v3 SNOMED CT Definitions 3.4Observation, Condition, Diagnosis, Concern NOTE: The HL7 Patient Care Technical Committee is developing a formal model for condition tracking. The examples provided here are greatly simplified so as to illustrate certain aspects of SNOMED CT implementation. Observations, Conditions, Diagnoses, and Concerns are often confused, but in fact have distinct definitions and patterns. "Observation" and "Condition": An HL7 observation is something noted and recorded as an isolated event, whereas an HL7 condition is an ongoing event. Symptoms and findings (also know as signs) are observations. The distinction between "seizure" and "epilepsy" or between "allergic reaction" and "allergy" is that the former is an observation, and the latter is a condition. SNOMED CT distinguishes between "Clinical Findings" and "Diseases", where a SNOMED CT disease is a kind of SNOMED CT clinical finding that is necessarily abnormal: [ 404684003 | Clinical finding ] [ 64572001 | Disease ]

26. 26 HL7 v3 SNOMED CT Definitions, contd… "Diagnosis": The term "diagnosis" has many clinical and administrative meanings in healthcare A diagnosis is the result of a cognitive process whereby signs, symptoms, test results, and other relevant data are evaluated to determine the condition afflicting a patient. A diagnosis often directs administrative and clinical workflow, where for instance the assertion of an admission diagnosis establishes care paths, order sets, etc. A diagnosis is often something that is billed for in a clinical encounter. In such a scenario, an application typically has a defined context where the billable object gets entered. "Concern": A concern is something that a clinician is particularly interested in and wants to track. It has important patient management use cases (e.g. health records often present the problem list or list of concerns as a way of summarizing a patient's medical history).

27. 27 HL7 v3 SNOMED CT Definitions, contd… Differentiation of Observation, Condition, Diagnosis, and Concern in common patterns: "Observation" and "Condition": The distinction between an HL7 Observation and HL7 Condition is made by setting the Act.classCode to "OBS" or "COND", respectively. The distinction between a SNOMED finding and SNOMED disease is based on the location of the concept in the SNOMED CT hierarchy. There is no flag in a clinical statement instance for distinguishing between a SNOMED CT finding vs. disease. "Diagnosis": Result of a cognitive process: Could potentially be Indicated by post- coordinating a SNOMED CT finding method attribute with a procedure such as "cognitive process". Directs administrative and clinical workflow: These use cases typically rely more on the context in which the diagnoses are entered (e.g. where an order set has a field designated for the admission diagnosis). In such a case, the distinction of a (particular kind of) diagnosis is that it occurs within a particular organizer (e.g. a condition within an Admission Diagnosis section is an admission diagnosis from an administrative perspective).

28. 28 HL7 v3 SNOMED CT Definitions, contd… Differentiation of Observation, Condition, Diagnosis, and Concern in common patterns: "Observation" and "Condition": The distinction between an HL7 Observation and HL7 Condition is made by setting the Act.classCode to "OBS" or "COND", respectively. The distinction between a SNOMED finding and SNOMED disease is based on the location of the concept in the SNOMED CT hierarchy. There is no flag in a clinical statement instance for distinguishing between a SNOMED CT finding vs. disease. "Diagnosis: Result of a cognitive process: Could potentially be Indicated by post-coordinating a SNOMED CT finding method attribute with a procedure such as "cognitive process". Directs administrative and clinical workflow: These use cases typically rely more on the context in which the diagnoses are entered (e.g. where an order set has a field designated for the admission diagnosis). In such a case, the distinction of a (particular kind of) diagnosis is that it occurs within a particular organizer (e.g. a condition within an Admission Diagnosis section is an admission diagnosis from an administrative perspective). Something that is billed for: The fact that something was billed for would be expressed in another HL7 message. There is nothing in the pattern for a diagnosis that says whether or not it was or can be billed for.

29. 29 HL7 v3 SNOMED CT Definitions, contd… "Concern": The HL7 Patient Care Technical Committee is developing a formal model for condition tracking. In that model, a problem (which may be an Observation, a Procedure, or some other type of Act) is wrapped in an Act with a new Act.classCode CONCERN. The focus in this guide is on the use of SNOMED CT, whereas the Patient Care condition tracking model is the definitive source for the overall structure of a problem list. It should be noted that the administrative representation of a diagnosis and the representation of a concern break the rules from section 3.1.1 Observations vs. Organizers, in that these designations are based on context, whereas the designation of something as an Observation vs. Condition is inherent in the clinical statement itself.

30. 30 HL7 v3 SNOMED CT XML Examples: Clinical Finding Example 16. Assertion of a clinical finding Headache The observation is asserting a clinical finding of "headache".

31. 31 HL7 v3 SNOMED CT XML Examples: Diagnosis Example 17. Context-dependent (administrative) assertion of a diagnosis Hospital Admission Diagnosis Hospital admission diagnosis of headache That a given diagnosis is, for instance, an Admission Diagnosis, can be asserted by wrapping the observation within a particular organizer.

32. 32 HL7 v3 SNOMED CT XML Examples: Concerns Example 18. Example of a problem list containing concerns Problem List Headache Osteoarthritis of knee

33. 33 HL7 v3 SNOMED CT XML Examples: Concerns, contd…. That a given clinical statement is a part of a condition tracking structure can be asserted by containing the clinical statement within the concern act, using the mechanism defined by the HL7 Patient Care Technical Committee, as shown here.