1. Developing the Patient Centred Coordination Plan Profile A work in progress Jon Hilton, Health Informatics Society of Australia 15 th April 2010

2. PCC Planning Committee IHE profile development – the process The conceptThe concept –To provide efficient support for planned care and follow-up in Chronic Disease Management (CDM) Research and the proposal – Chronic Care CoordinationResearch and the proposal – Chronic Care Coordination –Discussions with local colleagues, colleagues from GE –Review of the Patient Plan of Care profile –Discussion with the IHE International Patient Care Coordination technical committee –The vote Into the international domainInto the international domain

3. PCC Planning Committee Starting out The workshopThe workshop –IHE Australia – December workshop –Excellent discussion –Broad and active participation Beyond referralBeyond referral

4. PCC Planning Committee Developing the profile Documentation & templatesDocumentation & templates Draft profileDraft profile Robust discussionRobust discussion –To workflow or not to workflow – technical issues, documents and metadata –When is a care plan not a care plan? The Patient Plan of Care profile revisited. Endless teleconferences and a new name – Patient Centred Coordination PlanEndless teleconferences and a new name – Patient Centred Coordination Plan

5. PCC Planning Committee PCCP – creating a plan Register Coordination Plan Register Plan Tasks Care CoordinatorCare ProviderRegistry/Repository Create Coordination Plan Notify Plan Task Acknowledge Plan Task Retrieve Plan Task Retrieve Coordination Plan

6. PCC Planning Committee PCCP – Task Report Care Coordinator Care Provider Registry/Repository Create Task Report Register Task Report Notify Task Report Acknowledge Task Report Register Associated documents

7. PCC Planning Committee PCCP - Review Care CoordinatorRegistry/Repository Query care tasks"not on track" Care plan document list Retrieve Care Task Reports Care Task Report documents

8. PCC Planning Committee Building on XDS This profile uses IHE Infrastructure toThis profile uses IHE Infrastructure to –Associate documents such as care plans and reports in a structured fashion –Notify care team members of events such as care plan creation –Manage secure access to documents using web services –Allow care managers to monitor plans –Use metadata to identify tasks requiring attention Some relevant profiles and standardsSome relevant profiles and standards –XDS.b, XDM, XDR (www.ihe.net - technical profiles) –Document Metadata Subscription (DSUB) –HL7 CDA Release 2.0 (CDAR2)

9. PCC Planning Committee Progress to date Draft profile still needs a lot of workDraft profile still needs a lot of work Frustration and not enough timeFrustration and not enough time –Some of the concepts are subtle and difficult to explain –Found myself explaining the same concepts repeatedly –Constant battle to find time to update documentation Support from unexpected quartersSupport from unexpected quarters IHE Face-to-face 26 th -29 th AprilIHE Face-to-face 26 th -29 th April –I should be there, but overseas colleagues have been patient and supportive –I have been able to arrange “eyes, ears and legs on the ground”

10. PCC Planning Committee The future – where to from here? Outcome of the Face to face meeting is likely to be a recommendation that we take more time to develop this profileOutcome of the Face to face meeting is likely to be a recommendation that we take more time to develop this profile U.S. National Quality Forum - Care CoordinationU.S. National Quality Forum - Care Coordination –Dr. David Stumpf is providing excellent support – he agreed to be my “legs on the ground” –He is also interested in taking the concepts further within the NQF CDA and Green CDA – hData and RESTCDA and Green CDA – hData and REST –Current large, heavyweight standards are acknowledged as a problem –GreenCDA and hData Australia is apparently leading the world in this areaAustralia is apparently leading the world in this area