This track continues a successful series of connectathons since January 2017 focused on applying evidence-based clinical practice guidelines at the point of care to create and share individualized patient care plans and to manage their ongoing care. Specific clinical scenarios are provided for Hypertension care management and COVID-19 ED severity risk assessment, but participants are invited to share work on use of clinical guidelines for other care management scenarios.
Computable clinical practice guidelines (CPGs) and pathways help deliver actionable knowledge at the point-of-care and support evidence-based care planning and coordination among all participants in a patient’s care team. This track will evaluate, test and demonstrate implementation guidance that leverages the strengths of both HL7 and OMG standards to deliver evidence-based care recommendations integrated into the clinical workflow. Care Management requires integration of FHIR resources for patient care (CarePlan, CareTeam, Goal, Condition, Observation and others) with the definition of computable clinical guidelines and protocols using HL7 CPG-on-FHIR (PlanDefinition, ActivityDefinition and CQL) and/or OMG BPM+ Health standards.
Logica Health is developing a Care Management IG that integrates standards from HL7 FHIR Clinical Guidelines IG and OMG BPM+ Health to improve approaches for delivering executable clinical guideline recommendations and care pathways as part of Clinical Decision Support (CDS) and patient-centered care planning.
- This track will provide an opportunity to share experiences with developing computable CPGs and deploying executable guidelines to clinicians using SMART on FHIR apps and/or CDS Hooks.
Improve patient-centered care management:
Create patient-specific care recommendations based on applicable clinical practice guidelines and care pathways, delivered at the point-of-care to clinicians and patients.
- Create or update patient-specific care plans to coordinate care between primary care and specialists, different provider organizations, and with patients and caregivers.
- Support ongoing care management and coordination between all participants in a patient's care team using interoperable clinical process models and clinical pathways.
- Test an Implementation Guide
Please use this Zulip topic for discussion during (and after) the Connectathon. Chat will be disabled within the Zoom meetings for all tracks.
Care Management Track (https://chat.fhir.org/#narrow/stream/179207-connectathon-mgmt/topic/Care.20Management.20Track)
Submitting Work Group/Project/Accelerator/Affiliate/Implementer Group
HL7 Patient Care WG
Proposed Track Lead
Dave Carlson, firstname.lastname@example.org
- Clinical Reasoning
- Care Coordination
- FHIR R4
Specification(s) this track uses
HL7 FHIR Clinical Guidelines IG (CPG-on-FHIR)
OMG BPM+ clinical pathways
Plus, OMG MDMI 2.0 standard for mapping pathway data elements to FHIR data sources
HL7 FHIR standards for Patient-Centered Care Planning
CarePlan, Condition, Goal, Request-type resources, Observation, and more
- Multiple Chronic Conditions (MCC) electronic Care Plan Project
- MCC HL7 Confluence FHIR IG page https://confluence.hl7.org/display/PC/MCC+eCare+Plan+FHIR+IG
HL7 CDS Hooks & SMART-on-FHIR apps
Present guideline recommendations within EHR clinician workflow
Engage patients in shared decision making and self-management of chronic conditions
- GE Healthcare
- Mayo Clinic
- MDIX, Inc.
- Veterans Health Administration
- Model Driven Solutions
- University of Utah
- Add you organization here!!
Connectathon Management > Care Management Track
Thursday Sept 10th, 10:00am ET within the connectathon Zoom.
Resources and Artifacts
Logica FHIR Sandbox
- Secured FHIR Server URL:https://api.logicahealth.org/CareManagement/data
- Open FHIR Server URL:https://api.logicahealth.org/CareManagement/open
Sample Patient Data
We list separate roles for CPG developers using HL7 Clinical Guidelines IG and OMG BPM+ models, however we are particularly interested in efforts to leverage integrated use of these standards. For example, a clinical pathway designed using a BPMN process model or CMMN case model that calls decision services via CDS Hooks API that are implemented using FHIR Clinical Guidelines IG.
|CPG-on-FHIR Developer||Develop computable clinical practice guidelines using the HL7 Clinical Guidelines IG, delivered as profiled FHIR PlanDefinition, ActivityDefinition and ValueSet resources, plus CQL logic libraries.|
|BPM+ Pathway Developer||Develop computable clinical pathways using OMG BPM+ models (BPMN, CMMN, and/or DMN), delivered as interoperable knowledge artifacts that include bindings to FHIR clinical data resources.|
|CPG Execution Service|
Provide a server with REST services to load and execute clinical guideline and pathway models using FHIR clinical data sources.
|Clinician CPG client app|
Client application that requests guideline recommendations from CPG Execution Service for presentation to clinicians or patients.
|Care Planning Service|
Provide a server with FHIR APIs used to create, update, and retrieve FHIR Care Plans with associated resources (including Goal, Condition, Request-type resources, etc.).
Scenario: Hypertension Care Management
This Hypertension treatment scenario is excerpted from Intermountain Healthcare’s Management of High Blood Pressure guideline and will be used to create targeted examples that support all track System Roles.
Patient has diagnosis of Hypertension on active problem list
Select using value set with SNOMED CT and ICD-10 codes
Patient is not pregnant
Patient does not have active prescription for ACE-I or ARB
Most recent BP within last 4 weeks is:
> 140/90 if patient has CKD and/or Diabetes comorbidity
> 130/80 otherwise
NOTE: these are not complete guideline criteria, but serve to illustrate implementation approaches.
Initiate treatment with ACE-I (or ARB): lisinopril (or losartan)
Lisinopril, 10mg daily
Rapid cycle: Evaluate BP every two weeks while titrating or switching meds.
Increase to Lisinopril, 20mg daily if BP is not within management target.
Referenced Value Sets
ACE-I and ARB RxNorm codes
Diagnosis of Hypertension
Chronic Kidney Disease All Stages (1 through 5)
Scenario: COVID-19 Severity Score and ED Disposition
This scenario is based on an active, open source project underway as part of the COVID-19 Healthcare Coalition. The ED Severity Classification project has been developed with the involvement of the American College of Emergency Physicians (ACEP).
For adults presenting to the Emergency Department (ED) with possible or confirmed COVID-19, provide a Clinical Practice Guideline and decision support tool that helps classify patient disease severity and give guidance on appropriate disposition. This tool will be accessible by emergency physicians in a workflow-friendly manner to assist in management of their patients in several ways:
- Diagnostic workup – can be accessed early in the encounter of a patient with suspected or confirmed COVID to determine appropriate diagnostic testing.
- Disposition – can be accessed after diagnostic testing has been performed to determine the safest disposition for the patient.
- Resource Anticipation – the algorithm is structured to be able to be run in the background and have data presented on an ED or Hospital Tracking Board to be able to anticipate resource and bed needs.
Technical Scenario: Hybrid Architecture
The Care Management Track is pursuing a hybrid architecture to allow for testing alternative approaches that leverage and use alternative standards from HL7 and OMG to achieve computable, re-useable and, ultimately, automated Clinical Pathways / Clinical Guidelines.
For the September 2020 Connectathon, the hybrid work track will focus on using the OMG Standards for Design Phase of Care Management Pathways and using the HL7 standards in the Implementation Phase of Care Management Pathways. At the present time, Standards being considered in this track are the Object Management Group’s (OMG) BPM+ Standard (BPMN, CMMN, DMN, SDMN),and MDMI. HL7 Standards being considered are FHIR, CQL, ANF, and CDS Hooks. Recommendations for and inclusion of other standards are welcome.
Testing different approaches will start with identifying a scenario and within the scenario one or more small use cases will be selected. For example, in the Intermountain Hypertension Guideline scenario, the use case of the decision task for "Has the Patient met their Blood Pressure Goal" has been selected. Others will be considered, time permitting.
Each Use Case within a Scenario has the same start point; a description of the Use Case from a Clinician’s view. From this start point, the goal is to create end-to-end implementation in a standards-based platform. Besides testing and evaluating the different approaches, an objective is also to identify gaps and issues there may be in the standards. For each Scenario and User Case identified, there will then be a definition of the Standards technology stack used for the design and implementation phases.
Hybrid Work Stream
For this Connectathon, the Hybrid Work Stream wants to test: Can a standards-based Clinical Pathway be shared and re-used by different healthcare organizations that have different execution software platforms? The focus of this workstream will be standards from HL7 and the OMG. For testing this premise, the Task of “Has the Patient Met their Blood pressure Targets” from the Intermountain Hypertension Clinical Pathway was selected and modified to specifically test some elements of this premise. The following graphic represents the modification:
A further consideration for this specific work stream is many of the participants involved are investigating a standards-based approach for implementing Clinical Pathways is will this approach better process improvement withing a Clinical Pathway. The work stream is also testing the approach of separating of concerns to isolate and localize change. The 3 concerns identified were process, decisions, and data. Although separate, these areas need to be linked.
For this use case and for each concern, the objectives and probable participants are as follows. Other participants are always welcome and encouraged.
- Process: Can BPM+ tooling that are used to design process workflow produce “models” be executed on different standards-based software platforms?
- Probable BPM+ tools standards based tools are Trisotech and Red Hat.
- Probable standards-based execution platforms are different jpmn software engines and FHIR Plan Definition software.
- Rules / Decisions: Can decisions be expressed at a design level and executed on different standards-based software platforms?
- For this use case, there is no standard-based specific expression language used.
- Probable standards-based execution platforms considered are DMN, CDS Hooks, and CQL.
- Data: Can data / information be expressed at the design level and integrated with different implementation platforms.
- At the design level, probable standards-based data models considered are FHIR, ANF, MDMI, and SDMN.
- Probable standards-based execution platforms are FHIR (Book Zurman and Logica). Other data implementation besides FHIR are welcome.
Track Report Summary
This track is focused on applying evidence-based clinical practice guidelines at the point of care to create and share individualized patient care plans and to manage patients' ongoing care. A Hypertension clinical practice guideline (CPG) from Intermountain Healthcare was used as a focus for discussion and examples of computable CPG recommendations and a clinical pathway represented using both HL7 CPG-on-FHIR and OMG BPM+ standards.
- Focus on improving patient care with evidence-based clinical pathways
- Enable “hybrid” architecture and development with standards
- HL7 FHIR Clinical Guidelines IG
- HL7 Clinical Quality Language (CQL)
- OMG BPM+ Health (process, case, and decision platform-independent models)
- Integration with HL7 FHIR IG for dynamic care planning
- Separation of concerns and relationship between pathways, CPG recommendations, and Care Plans, as summarized in diagram below.
- Very productive discussion about Hypertension care management based on first-hand experience by practicing MDs.
- Deep-dive review of initial BPMN and DMN model for Hypertension care management based on Intermountain guideline.
- Demonstration of patient persona clinical data within Logica sandbox, including EHR Simulator to launch SMART apps and display patient-view CDS Hook cards.
Issues and Questions
- Emphasized need to expand use of and support for Encounter within the FHIR sample data and CDS logic related to Hypertension care management, e.g. to omit blood pressure observations from emergency care or inpatient encounters when assessing Hypertension controlled/uncontrolled status and care plan recommendations.
- Increase emphasis on care coordination for Hypertension management, including challenges summarized by Dr. Bruce Bray:
- Med coordination and adjustments
- Communication process between Pharmacy, primary care and specialty care
- Process for electronic refills of prescriptions
- Direct monitoring of labs (e.g. potassium levels)
- Communicating across several software and communication platforms (Dr. Bray works virtually with rural Utah and Wyoming clinics)
- Telemedicine encounters and use of patient-generated device data from home