chronic care coordination/community referral workflow brief profile proposal for 20010 - 20011...
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Chronic Care Coordination/Community Referral Workflow
Brief Profile Proposal for 20010 - 20011Brief Profile Proposal for 20010 - 20011presented to thepresented to the
PCC Planning CommitteePCC Planning Committee
Jon Hilton, Health Informatics Society of AustraliaJon Hilton, Health Informatics Society of Australia1010thth September, 2009 September, 2009
PCC Planning CommitteePCC Planning Committee
The Problem
• To provide efficient support for planned care and follow-up To provide efficient support for planned care and follow-up in Chronic Disease Management (CDM)in Chronic Disease Management (CDM)
• Care Management Profile (CM) links guidelines for care Care Management Profile (CM) links guidelines for care with clinical data sourceswith clinical data sources– In CDM, guidelines are typically embodied in a simple care plan In CDM, guidelines are typically embodied in a simple care plan
that specifies referrals to a care team. Tracking of referral with that specifies referrals to a care team. Tracking of referral with reporting by exception on clinical issues is an efficient way to reporting by exception on clinical issues is an efficient way to support care management.support care management.
– Existing care planning and management systems are already Existing care planning and management systems are already implementing this functionality and would benefit from a implementing this functionality and would benefit from a standardised approachstandardised approach
• This is foundational work required to support business This is foundational work required to support business processes and decision making in planned care for CDMprocesses and decision making in planned care for CDM
PCC Planning CommitteePCC Planning Committee
Use Case
• Doctor creates and lodges a copy of the care plan in a Doctor creates and lodges a copy of the care plan in a shared repository, and creates electronic referrals to the shared repository, and creates electronic referrals to the care team. Doctor asks patient to arrange appointments.care team. Doctor asks patient to arrange appointments.
• Each member of the care team acknowledges receipt of Each member of the care team acknowledges receipt of the referral. As appointments are made and attended, the referral. As appointments are made and attended, each member lodges a referral record and record of each member lodges a referral record and record of encounter (optionally flagged for non urgent attention) in a encounter (optionally flagged for non urgent attention) in a shared repository. Urgent clinical needs are addressed by shared repository. Urgent clinical needs are addressed by providers as usual.providers as usual.
• Doctor is able to access the shared repository and can Doctor is able to access the shared repository and can identify non attendances and flagged records of encounter identify non attendances and flagged records of encounter for further attention.for further attention.
PCC Planning CommitteePCC Planning Committee
Proposed Standards & Systems
• IHE XDS, XDS-MS, IHE PCC Content ProfilesIHE XDS, XDS-MS, IHE PCC Content Profiles• HL7 REFHL7 REF• Alternatives exist in the PCC Content Profiles (see Alternatives exist in the PCC Content Profiles (see
discussion on CM above for rationale for new proposal)discussion on CM above for rationale for new proposal)
PCC Planning CommitteePCC Planning Committee
Discussion
• The intention is to start with a well chosen foundation that The intention is to start with a well chosen foundation that can be built over time. Such an approach would allow can be built over time. Such an approach would allow maximum flexibility while minimising cost of entry and time maximum flexibility while minimising cost of entry and time to develop profile.to develop profile.
• Profile Editor: Profile Editor: Jon Hilton (Jon Hilton ([email protected]), Health Informatics ), Health Informatics Society of Australia (HISA)Society of Australia (HISA)
• The aim here is to take advantage of existing standard The aim here is to take advantage of existing standard messages and profiles where possible. Given the messages and profiles where possible. Given the potentially very broad user base, the intention is to design potentially very broad user base, the intention is to design the profile to support a low effort and cost entry point for the profile to support a low effort and cost entry point for providers with often unsophisticated systemsproviders with often unsophisticated systems