• Review of MCC eCare IG January 2023 ballot schedule
• Review and discussion of latest updates to MCC IG

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• Walk through of comment-only balloting plan
• Multiple Chronic Care (MCC) IG - overview of current state

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Meeting ID: 532 857 1160

• CANCELED

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Meeting ID: 532 857 1160

• CCDA Erata Publication Discussion 
• Review Select MCC FHIR Profiles 
• PACIO Topics 

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Meeting ID: 532 857 1160

• Connectathon 31 Planning
• MCC SDOH Guidance in IG
• Conditions Value Set Library

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Meeting ID: 532 857 1160

Slides: 2022-08-03 PCWG MCC eCare Plan Meeting Slides.pdf

Meeting Minutes: 2022-08-03 MCC eCare Plan Meeting

• MCC approach to value sets.
• Use of Flag resource for MCC use cases.

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Meeting ID: 532 857 1160

• Use of Observation.Focus to describe factors from caregiver related to ability to care give

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• Use of _include Search Parameter to link FHIR resources
• MCC Profile Updates
• Upcoming Meetings

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Meeting ID: 532 857 1160

• Overview and Progress Updates
• HL7 Connectathon 30 recap and Connectathon 31 plans
• Long COVID Data Elements Analysis update
• Support for Linking FHIR Resources Together
  • Use of Cardinality and Must Support
  • Use of _include Search Parameter

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Meeting ID: 532 857 1160

• HL7 May Connectathon 30 Overview
• Scenario Data Review
• Future Care Team Scenario (including SDOH support)
• May Workgroup Meeting
  • PACIO Birds of a Feather
• PCWG MCC eCare Plan Report Out (Thurs Q1)
• Collaboration with LHS - Care Team DAM Project (Thurs Q4)
• Other relevant sessions

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Meeting ID: 532 857 1160

• FHIR Goal Resource
  • Show and tell of MCC Goal Resource and Gravity Goal Resource approaches
  • Discuss similarities and differences
  • Identify gaps remaining
• Interoperable goals
  • Capturing goals in provider/patient interaction to conform to Goal resource
  • Storage for goals i.e., MCC proposed approach
  • Display patient-authored goals in clinician app

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Meeting ID: 532 857 1160

• Profile and Value Set Approach (15 min)
• FHIR: Handling Barriers and Supportive Factors (10 min)
• Care Planning Connectathon Track Planning (10 min)
• USCDI - Care Planning Data Elements (25 min)

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• PACIO x Care Planning Connectathon Track Discussion (20 min)
• Care Planning Connectathon Track Participation (5 min)
• Provider and Patient/Caregiver App Demo and Discussion (35 min)

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• Brief background and progress update
• IG redesign
• Long COVID domain
• Connectathon
  • Connectathon 29 recap (2022-01 Care Planning Track)
    • JIRA added to add Goal.addresses search parameter
    • FHIR-I: approach for adding Barriers and Supportive Factors to applicable FHIR resources
  • Connectathon 30 plans (2022-05 Care Planning Track)
• MCC eCare IG balloting timeline and PSS update

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• HL7 FHIR Connectathon planning - Care Planning track

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Meeting ID: 532 857 1160

• CMS Digital Quality Measurement Blue Print 

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Meeting ID: 532 857 1160

• Review Intervention Value sets

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Meeting ID: 532 857 1160

• Review Health Status and Evaluation Value Sets

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Meeting ID: 532 857 1160

Zoom Viewer Version:

the link below to share this recording with viewers:
https://us02web.zoom.us/rec/share/cqbWCHta7QPUmuGaV7rW6qj5zcLPV71YKbnf4NuxHPqt4GzpS1y_y47XEmVl8el1.aWgA27Z5qbpgJL2X 

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• Provide a brief update on the MCC eCare plan project (the pilot team perspective)
• Q&A with Laura Marcial, Dan Vreeman, and David Dorr

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Progress: Review last session (6/23), including a discussion of

issues around defining the creation of computable goals as needed for multiple chronic conditions, as well as associated issues in structuring the requisite data.

Plan:

1) Health Status elements review

2) Specific Care Plan issues for Multiple Chronic Conditions

3) Open Discussion

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Meeting ID: 532 857 1160

Progress :

Review last session (6/9), included a discussion of issues around goal model in a variety of projects including MCC eCare Plan, The Gravity Project, FHIR Clinical Guidelines (CPG), PACIO,  and Problem-based Charting/Provider Notes/Team Management  

Plan:

1) Problem Definition: Creation of ‘computable goals’

2) Available tools for

   a- Structuring the guideline

   b- Formalizing the expression

   c- Accessing the data

3) Open Discussion

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Meeting ID: 532 857 1160

Progress: Review last session (5/12), including: 

1) Project status update

2) Patient Administration update

3) Concept modeling for MCC Process Use Contexts

Plan:

1) Review Goal data element strategy

2) Invited speakers on MCC Goals, SDoH Goals, and Goals from the perspective of Problem-Based Charting and Provider Burden

Open Discussion

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Meeting ID: 532 857 1160

Recording, attendees and speakers listed here: June 9, 2021 Care Plan Topics Meeting Notes

• Progress: Review last session (4/28), including 
  • Review Social Health Concern data elements
  • Primer on how we use data element domains such as Pain and Food Insecurity
• Plan:
  • Project status update
  • Patient Administration update
  • Concept modeling for MCC Process Use Contexts
• Open Discussion

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Meeting ID: 532 857 1160

• Progress: Review last session (4/21) including
  1. Pain Domain elements and 
  2. Implications of the FHIR Care Plan Content Model relative to coverage for Multiple Chronic Conditions
• Plan: 
  1. Review Social Health Concerns Data Element 
  2. Primer on how we use data element domains such as Pain
• Open Discussion

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Meeting ID: 532 857 1160

• Progress: Value Set practices for MCC and CardioVascular Disease element review
• Plan: Pain Domain element review and FHIR Care Plan Content Model implications for MCC
• Open issues discussion

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Meeting ID: 532 857 1160

• Progress 
  • review last meeting
  • provided additional outcomes/goal model input 
  • reviewed Diabetes elements
  • value set tooling considerations
• Plans 
  • value set naming practices applied to MCC eCare Plan
  • review CardioVascularDisease elements 
• Predicaments - no new issues
• Open Discussion with specific questions for the WG

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Meeting ID: 532 857 1160

• Progress (including recap from last meeting)
• Plans (what we’re currently working on)
• Predicaments (issues deliberately deferred)
• Open Discussion

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Meeting ID: 532 857 1160

5:00-6:00 PM

• Project Scope Review: problems and goals for MCC eCare Plan
• Care Plan information model discussion
• Strategy on increasing from one condition to multiple conditions
• Discuss workgroup's recommendation on best collaboration practices
• General discussion

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Meeting ID: 532 857 1160

• Review MCC FHIR IG
• Review MCC Github 

• Connectathon Schedule and call to participate

• Workgroup meeting schedule:2021 January WGM Patient Care Agenda and Minutes

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Meeting ID: 532 857 1160

• Care Coordination track patient story, scenarios, and artifacts for testing: Connectathon Track Participation Sign Up
• Leveraging Novel Technologies for Chronic Disease Management for Aging Underserved Populations the RFI may be downloaded from the Federal Register at: https://www.federalregister.gov/documents/2020/11/17/2020-25328/request-for-information-landscape-analysis-to-leverage-novel-technologies-for-chronic-disease. 

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Meeting ID: 532 857 1160

• Care Coordination track orientation and plans for testing: Connectathon Track Participation Sign Up

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Meeting ID: 532 857 1160

• VSAC Authoring Permissions
  • Request the addition of a steward 
• Change in primary contact/author for IG and PSS
• Update ownership of HL7 Github

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Meeting ID: 532 857 1160

• Should Care Plan be a data class in USCDI
• Review of Draft Implementation Guide

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Meeting ID: 532 857 1160

• General IG Review 
• Review the profiles MCC will test in Sept Connectathon
• Discuss "Custodian/Care plan Owner"
• Connectathon Planning Updates
• Date and time for Patient Care Care Planning meeting during the HL7 workgroup meeting

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Meeting ID: 532 857 1160

• Medication Statement Vs US Core MedicationRequest within Care Plan Intervention (aka OutcomeReference)
• A general overview of the current state of IG dev
• Bonus if time allows* connectathon track (revised) plans
• Discuss Care Plan maintained by (Plan Monitor Name)

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Meeting ID: 532 857 1160

• Review Goals Profile Diagram
• Review and Request to vote on approval of the FHIR IG Proposal: Multiple Chronic Conditions Dynamic Electronic Care Plan FHIR IG Proposal
• Status on all things care plan page

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Meeting ID: 532 857 1160

• Review IG changes/additions
• Review Chronic Kidney disease Profile relationship diagram changes
• Review Care Plan profile relationship diagram
  • Including Questionnaire integration
• Development of education material
  • All things care plan page
  • 5 minute education videos 

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Meeting ID: 532 857 1160

• Relationship diagrams for the Care Plan and CKD profiles
• How the IHE dynamic care plan can help to inform the relationship diagrams for those profiles

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Meeting ID: 532 857 1160

The MCC project will invite the larger stakeholder group to the patient care call for an overview of the project and a  progress status

Full Agenda

• Background
• Project Scope
• Approach
• Project Status
• Next Steps

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Meeting ID: 532 857 1160

PSS Review

Status of Content Profiles

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Meeting ID: 532 857 1160

Debrief on the Care Coordination Track

PCWG schedule past for June

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Meeting ID: 532 857 1160

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Meeting ID: 532 857 1160

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Meeting ID: 532 857 1160

Confirmation of upcoming Care Plan meetings/cancelations (Katiya- 5 minutes)

MCC PSS editing ( Gay- 15 minutes)

IPS Vote ( IPS Lead/PCWG- 15 minutes)

Recording of Care plan overview (Lisa/group- 25 minutes)

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Meeting ID: 532 857 1160

HL7 May Connectathon Care Coordination Track Plan 

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Meeting ID: 532 857 1160

April 8, 2020*

*Joined the care plan DAM call to discuss:

Care team Attribution

Subscription to care plan updates 

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URL: https://join.freeconferencecall.com/patientcare

• Phone Number: +1 563-999-2090
  • Participant Passcode: 792564

Transaction for Care Team Attribution

Subscription to Care Plan Updates 

IG Development Process

IG Task Plan/ Upcoming Agendas

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Separate listserve

MCC CIMs

Free conference call recording and sending the list of the attendee

Confluence page for questions that arise out of the project

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Communication plan

US Core Care Plan - Discussion and Clarification

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