Health Status Evaluation and Outcomes Lisa Nelson, MS, MBA Have we mixed things up? Can we sort them out better now to avoid making ourselves nuts later?
Agenda • Why talk about this here? • The basic model for care plan information • Health Status Evaluation and Outcomes • Health Concerns
Why Are Care Plans So Important? Positive Health Triple Aim Outcomes for the Patient Thomas Feeley, M.D., “Transforming Medicine Through Value - Based Healthcare”.
Care Plans Plenty of Experimentation and Exploration!
12 Care Plan Standards Initiatives Initiative Technology (Vendor) Standard • • C-CDA 2.1 Care Plan Document HL7/BCBSA: Care Plan Proof of Concept ZeOmega • (2015) Edifecs Template • • GSI Health Care Plan DAM • Healthwise • • Greater New York Hospital Association: GSI Health Builds off BCBSA Proof of • NY DSRIP Implementation. Phase 1 Pilots Crimson/ Epic Concept Project • • (Jan 16 to Nov 16); Phase 2 Pilots (Jan Altruista C-CDA 2.1 Care Plan Document • 2017+) Intersystems (supports HealthIX HIE) Template • Allscripts • • VA Care Coordination for Improved Systems Made Simple (Lockheed) FHIR Care Plan Resource • Outcomes Challenge Care Plan DAM • • NIH NIDDK Chronic Kidney Disease (CKD) TBD C-CDA 2.1 Care Plan Document Care Plan Project Template • • Apple Care Plan Apple HealthKit IOS10 C-CDA CCD • • Early Hearing Detection and Intervention Epic IHE QRPH EHDI Hearing Care (EHDI) Hearing Care Plan Pilot: Oregon Plan of Care • Health Authority (June 2015) IHE PCD-01 • Utah Health Department Newborn C-CDA 2.1 • hearing screening care coordinaiton (ONC DIRECT • HIE Grantee): Utah Department of Health, IHE QRPH EHDI Hearing Care Of Utah Health Information Network (UHIN) Plan and Intermountain Healthcare (Sept 2015 to Sept 2016) 5
12 Care Plan Standards Initiatives – (continued) Initiative Technology (Vendor) Standard • • HL7 ePharmacy eCare Plan IG (based on NCPDP/HL7 Pharmacist eCare Plan Pilots QSI Data Systems • Community Care of NC (CMMI Grantee) • PioneerRX Pharmacy Software C-CDA 2.1 and FHIR Care Plan Resource) • Great Plains Area (ND, SD, IA, NE) of IHS • Rx30 • Computer RX • VIP Pharmacy Systems • Creative Pharmacist • • Connecticut Department of Social Services (DSS)/ CT DSS web-based CFC case C-CDA 2.1 Care Plan Document Template • University of Connecticut School of Nursing (CMS management system eLTSS dataset (in development) TEFT Demonstration) • • C-CDA 2.1 Care Plan Document Template Comprehensive Primary Care Initiative (CPC+) TBD Track 2 CMMI Grantee (target Q42018) • • Veterans Administration (VA) Salt Lake City Health TBD FHIR Risk Assessment Resource • Care System: Shared Care Planning FHIR Patient Resource • FHIR Goal Resource • FHIR Clinical Resources • FHIR Workflow Resource • • Argonaut Project Cerner Argonaut Implementation Guide (based • Epic on DAF FHIR Implementation Guide) • MEDITECH • McKesson • Surescripts 6
What Is Care Plan Information and How Does It Work Together? EVALUATION/OUTCOMES Evaluations/Outcomes HAS COMPONENT HAS COMPONENT HL7 Interoperability: Care Plan - Syntax Domain Progress - Structure Goal (mood Health Concern Toward Goal REFERS TO Analysis GOL) (code = - Semantics Observation CONCERN or Model (mood EVN) - Process RISK) (2016) (mood EVN) EVALUATES HAS REASON Supports HAS SUPPORT REFERS TO REFERS TO Intervention (mood: INT/RQO/ Outcome etc,) Observation Observation (mood EVN) (mood EVN) HAS REASON (mood: EVN) Care Plan Standards define ‘containers’ to capture and relate care plan information (Structure & Semantics) • • Intervention/activity (Action) Health concern/problem (Need/Issue) • • Evaluation/outcomes (Progress) Health goal (Goal/Objective)
The ask: Should we move the Health Status entry template into the Health Status Evaluation and Outcome section? 8
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