1. Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) June 19, 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 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 TBD 30

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 Types of preferences Communication preferences – who gets what information Treatment preferences Diet preferences End of life preferences (directives) Other preferences Reason for preference Religious or cultural influence Belief system Financial consideration Recommendation from others No reason stated Strength of preference Spectrum from absolute to if available HL7 Discussion– Preferences

8. 8 Reason for refusal Established concept in refusing immunization Value set exists Provider preferences Not currently captured Equivalent of recommendation or rationale Compared to provider bias HL7 Definition – Preferences, contd…

9. 9 Care Plan DAM – Preference View

10. 10 Questions/Comments to PCWG about Preferences Comment: The value set for advance directives could be constrained to a link/URL to a single source of truth about an individuals directives. Comment: The phrase here (under Types of Preferences) should be a preference stated in an advance directive because that can be part of the Care Planand there should be another whole section called Advance Directives that contains all the information including the advance directive preferences, and its that sections job to sort all that data out. To just say end of life preference is not specific enough. We need to say a value thats derived from an advance directive and then thats linked to a repository or document. Comment: Other preferences under Types of Preferences should probably be listed out/defined.

11. 11 Data elements with priority Health Concern Health Goal Interventions Ranking of priority Assignment of high-medium-low value set Not an ordering of list by relative priority Must you order multiple highs/mediums/lows? Allow for different priorities by patient and others Reason for priority? Care team members in different settings have different priorities – does this need to be in care plan model? Alternate perspective: do care team members have priorities only for health concerns they associate with HL7 Discussion – Priority

12. 12 Care Plan DAM – PriorityView

13. 13 Questions/Comments to PCWG about Priority Comment: Priority should not be included in interventions. Actions that were considered and not chosen as part of the intervention should definitely be included, but they should go elsewhere in the Care Plan. Comment: Interventions are the evidence of input by a particular discipline and are assigned to a particular discipline, so whether the discipline thinks it was important or not does not need to be included in the Care Plan output. Comment: A text field should be added with priority so that comments can be captured with priority rankings.

14. 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

15. 15 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

16. 16 Background Slides

17. 17 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

18. 18 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

19. 19 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

20. 20 "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…

21. 21 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 ]

22. 22 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).

23. 23 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).

24. 24 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.

25. 25 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.

26. 26 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".

27. 27 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.

28. 28 HL7 v3 SNOMED CT XML Examples: Concerns Example 18. Example of a problem list containing concerns Problem List Headache Osteoarthritis of knee

29. 29 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.