1. Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Patient Care WG Care Plan DAM August 14, 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. Agenda Goals Schedule Review of recommendations made to PCWG for Care Plan DAM –Items implemented in time for ballot –Items not implemented in time for ballot –Items not included in the DAM Next Steps 3

4. 4 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 and technical specifications Ongoing comments can be submitted and viewed on wiki: http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG Goals

5. 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 Mondays and 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

6. Schedule – August 2013 SUNDAYMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAY 123 45678910 11 AM ET Meeting Cancelled 11121314151617 11 AM ET Review of completed DAM with implemented recommendations 18192021222324 25262728293031 FINAL TIGER TEAM MEETING

7. Review of Final Balloted DAM Recommendations that were implemented in the DAM are in bold italic in this presentation. Recommendations that were not implemented (because they were process or not part of an informational model) are in italic. Majority of recommendations made were implemented in ballot documentation. 7

8. 8 Support Care Plan and Plan of Care Recommend that DAM should support both the Care Plan and Plan of Care, sequential and multi-threaded workflows; needs to define the buckets of all the information for all of these. The Care Plan structure is designed to support the implementation of different types of plans, including Treatment Plans, Plans of Care and Care Plans as defined by the ONC (LCC) Longitudinal Coordination of Care project. There is a generic Plan structure which together with a number of supporting components describe health concerns, health goals, interventions (plan activities), preferences, health risks, acceptance review, outcome review, care team roles, participations and their relationships. (PCWG Care Plan DAM Specification document, p 47, line 1550)

9. 9 Support Care Plan and Plan of Care Figure 6 Core Components of the Plan

10. 10 Goal Acknowledgment / Acceptance Recommend adding attribute to Goals that can indicate that the goals have been agreed to by both the Provider and the Patient or that there is not agreement between the two. Recommend adding another attribute that supports specific health concern and intervention related goals (who has agreed to these goals). Recommend including the ability in the model for a Care Team Member to accept/acknowledge their association Recommend allowing for variance analysis with levels of intervention. Recommend adding/supporting an ability to harmonize multiple treatments and Plans of Care and to create a Master Care Plan in the care of complex Patients in complex organizations.

11. 11 Goal Acknowledgment / Acceptance Figure 7 Associations Activity, Health Goal, Health Concern, Health Risk and Care Barriers

12. 12 Goal Acknowledgment / Acceptance Figure 9 Types of Reviews

13. 13 Goal Acknowledgment / Acceptance Figure 10 Care Team Conversations

14. 14 Goal Acknowledgment / Acceptance Figure 15 Plan Communications Logical Information Model

15. 15 Preferences Recommend adding a separate Advance Directives section that contains all preference information including advance directive preferences, which are linked to a repository or separate document. Recommend listing out and defining Other preferences under Types of Preferences.

16. 16 Preferences Care Preference Attributes (Care Plan DAM Specification, p64): A care preference is a statement expressed by the patient, custodian or caretaker responsible for the patient in order to influence how their care is delivered. A preference expresses a personal choice and may be driven by cultural, religious and moral principles. As such it is a principal component of patient centered care and autonomy. Care preferences serve as modifiers of the Care Plan which influence how the plan is personalized for the individual. A care preference may be specified prospectively to influence future care planning and treatment or it may be expressed and recorded at arbitrary decision points during interventions. A preference expresses a request to fulfill a patient's choice or desire. The choice may be a strong and absolute statement such as an end of life directive. The request could also be a desire to be fulfilled if possible given care team capabilities and resources.

17. 17 Preferences Attribute NameData TypeDescription preferenceCodeDescriptive code which specifies the type of the patient preference reasonCode[0..*] Captures a reason indicator for the preference. The reason may be classified as cultural, religious, moral/ethical. The reason is a factor which should already be included in considering the strength of the preference. It is explicitly indicated in the model in order to provide context for handling with sensibility. effectiveDateDateTimeThe date/time the preference becomes effective for consideration when providing care expressedByRole The individual who expressed the preference. This is typically the patient but it may also be the patient's caretaker (for a young child or a patient who is not able to decide for themselves). strengthLevelTypeThe strength indicates flexibility in the interpretation of the patient's choice by the care team participants. The strength may be High and indicate an absolute choice driven by moral principles, cultural or religious principles. Or it may indicate an important desire which the patient has but for which the patient has flexibility. The strength may have a value of either High (absolute choice) or Low (desired choice).

18. 18 Preferences notesNote[0..*] Optional notes about the preference. The note captures a text narrative, date of the note and the individual making the note. mediaURL[0..*] Optional link to external documentation supporting the preference (e.g. scanned advance directive or legal documents on file). activationCriteriaCriterion[0..*] Specifies how the preference is matched to an Intervention and the conditions under which it is activated. alternatePreference CarePreferenc e[0..*] A list of ordered alternate preferences acceptable to the patient or caretaker in case the primary preference cannot be fulfilled. The ordering indicates the next best alternative for the patient. acceptance AcceptanceRe view[0..*] Captures acceptance or acknowledgement of the preference by one or more care team members. Acceptance represents alignment of the patient and providers understanding. unfullfilledReason[0..1]Captures the reason why a preference cannot be applied during an intervention in which the preference should apply. This property can only be set for preferences associated with a Health Activity

19. 19 Priority Recommend not including Priority in interventions. Actions that were considered and not chosen as part of the intervention should be included elsewhere in the Care Plan. Recommend adding a text field with Priority so that comments can be captured with priority rankings.

20. 20 Priority Figure 7 Associations Activity, Health Goal, Health Concern, Health Risk and Care Barriers

21. 21 Levels of Association Recommend including associations in model for traceability (assignment of responsibility, payment, etc.): provide a bucket for association/responsibility level, bucket for functional role, and bucket for identification of responsible/associated individual or entity Recommend that High, Medium, Low be used as association/responsibility level designators for both Health Concerns and Interventions. Recommend that association should include individual and organization under functional role (Care Team Members may have more than one role inside an organization) Recommend that Health Concerns and Interventions also include type of association (e.g., fee for service, consent, other)

22. 22 Levels of Association Figure 8 Activity Associations

23. 23 Care Team Member: Role, Cardinality Recommend establishing 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). Recommend establishing Care Team Member cardinality: Health Concerns to Team Member Recommend Health Concern can be zero to many cardinality, with SHOULD conformance Goals to Team Member Recommend Goal can be zero to many cardinality, with SHOULD conformance Interventions to Team Member Recommend Intervention (Plan Activity) can be zero to many cardinality with SHOULD conformance

24. 24 Team Member Cardinality Figure 6 Core Components of the Plan

25. 25 Recommend a way to account for facilitation of the Care Plan (steward role or other) Care Plan Facilitation

26. 26 Care Plan Facilitation Figure 6 Core Components of the Plan

27. Opportunities to Engage in HL7 Balloting

28. Ballot Period Fall 2013 CDA Implementation Guide Ballot Cycle: Ballot Pool Sign-up: July 25, 2013 through Sept 9, 2013 Must join the ballot pool before Sept 9. Ballot Opens: Aug 16, 2013 Ballot closed: Sept 16, 2013 HL7 Ballot Website: http://www.hl7.org/participate/onlineballoting.cfm?ref=nav http://www.hl7.org/participate/onlineballoting.cfm?ref=nav

29. HL7 Ballot Information Page Hl7 Balloting Home Page Contains: Sept 2013 ballot calendar Non-Member balloting participation instructions Participation in balloting is available for HL7 Members and Non-Members (any interested party) – For Non-Members, there is a small administrative fee ($50) to participate

30. Access the HL7 Ballot Website Instructions and all links needed are on the homepage: Members and Non-Members must sign in to access the ballot desktop: Non-Members will need to create a profile to participate

31. Join the Ballot Pool After logging in, you will see a list of the available ballots on your Ballot Desktop: Select Join Ballot Pools from the menu on the right side of the screen:

32. Select ballot(s)to join from the left column: Join the Ballot Pool

33. Review Ballot Packages Ballot desktop includes ballot pools that you joined: Understand ballot documents Review ballot comment spreadsheet and instructions

34. Comment Spreadsheet Be specific about locationCopy and paste from Ballot Artifact You dont have to have proposed wording but specificity clarifies Tell us what you think is wrong or could be better Be sure to indicate if you want to be present during resolution of any/all comments

35. Vote Types- Affirmative Affirmative Vote with Comment- Suggestion (A-S) – Use this if the committee is to consider a suggestion such as additional background information or justification for a particular solution Affirmative Vote with Comment – Typo (A-T) – If the material contains a typo such as misspelled words, enter A-T Affirmative Vote with Question (A-Q) Affirmative Vote with Comment (A-C)

36. Vote Types- Affirmative Examples of affirmative votes:

37. Vote Types- Negative Negative Vote with reason, Major (Neg-Mj) – Use this in the situation where the content of the material is non- functional, incomplete or requires correction before final publication. – All Neg-Mj votes must be resolved by committee. Negative Vote with reason, Minor (Neg-Mi) – Use this when the comment needs to be resolved, but is not as significant as a negative major.

38. Vote Types- Negative Examples of negative votes:

39. Cast Your Vote Cast your overall vote Affirmative votes must have comments of an affirmative nature (Comment, Suggestion, Typo or Questions) Negative votes must have one or more negative comments (Negative Vote with Reason – Major or Minor) Attach the comment spreadsheet Submit your comments by the ballot close date: Monday, Sept 16, 2013 Select the Vote tab:

40. Following the Comment Period Reconciliation: – Starts during the working group meeting (Sept 22-27) – Continues during scheduled conference calls Overall committee vote – Incorporate changes and publish – Incorporate changes and back to ballot – Withdrawal of negatives

41. 41 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