Consumer Centered Care Planning Interoperability Showcase
Use Case Title: Care Coordination (Evidence based FHIR Dynamic Care Planning, CDS, Break the Glass based on Patient Consent)
HL7 FHIR standards are used to define and exchange clinical practice guidelines, a SMART on FHIR app is used by physicians to create a patient care plan and associated orders based on guideline protocol and evidence, and the patient’s resulting care plan and clinical record are shared among all members of the care team via a standards-based integration server platform. Care is coordinated between a patient’s primary care provider and specialist providers, including direct engagement with the patient at home.
See the HIMSS Interoperability Showcase - Consumer Centered Care Planning Use Case Video for a presentation of this use case. These presentations were given at least once an hour while the Interoperability Showcase was open.
Allscripts, Elsevier, Patient Link, VA (HSPC), Perspecta, Infinitt, VA
Diagram of the interactions among the Use Case Actors and Components
The “Sharing with Protections” Vignette within the Consumer Centered Care Planning Interoperability Showcase
This vignette featured dynamic management and sharing of a FHIR Care Plan for veteran patient persona, Amy Jackson, among the members of her Care Team using FHIR Resources and Security Labeling.
The specialists in the use case, a nephrologist and a podiatrist, are VA providers, both using an EHR viewer built on the Healthcare Services Consortium (HSPC) Sandbox.
Each specialist is able to view and update Amy’s shared Care Plan using a Smart on FHIR Care Planning App embedded in their EHRs.
The underlying Perspecta “HealthConcourse” platform enables the Smart on FHIR App to access, create, modify, and share FHIR Care Plan related Resources
The platform enables Amy to restrict sharing of her PTSD mental health medications with any non-mental health providers using security labeling.
After reviewing Amy’s medication list, the podiatrist begins an order an opioid medication for her diabetic foot pain. The podiatrist thinks an opioid medication is safe because the medication list displayed to the podiatrist does not include any contra-indicated drugs.
The podiatrist’s Clinical Decision Support (CDS) system is a “super-user” with access to all of Amy’s Care Plan information including her restricted mental health medication, which is masked in the podiatrist’s EHR viewer.
The CDS sends a FHIR CDS Hooks “card” alerting the podiatrist that ordering an opioid could be a patient safety issue, thereby prompting the podiatrist to “break the glass”, and override the restriction on access to the anti-anxiety medication, which triggered the medication contra-indication alert.
In addition to providing the adverse drug-drug interaction warning for opioids and anti-anxiety medications, the CDS also provides guidance about a suitable non-opioid medication alternative.
This break the glass scenario demonstrates that security labeling can be used to balance patient privacy with patient safety.
For technical details see HIMSS 201902 Sharing with Protections
Primary Care Physician:
Review Pt problem list from HIE. Finds dx of diabetes, CHF
Diagnosis Chronic Kidney Disease
Search Elsevier knowledge base with plan & activity definitions to create care plan
Turns plan definitions into care plan and activity definitions into requests.
See’s pt, retrieve record from HIE and pulls in problem list. Create Care Plan
Smart on FHIR App
Evidence Based Care Protocol Service
● Facilitate the search with patient’s conditions against Elsevier knowledge base.
● Serve evidence based Order Sets as FHIR Resources : Plan and Activity Definitions.
● Provide access to the evidences that drives the plan & activity definitions.
Order Sets & Care Plans
FHIR Server serving evidence based plan definitions.
● Pt pulls clinical data and Care Plan from the hub to aggregate in consumer app. This helps the pt to understand her condition and how she can take care of herself.
● Remote Patient Monitoring creates observation of activity (blood glucose monitor/assessments/patient reported data) and pushes it to HealthCourse via FHIR Questionnaire and QuestionnaireResponse?)
● Patient selects who has consent to receive their record
Patient presents with neuropathy and physician wants to prescribe opioids. The specialist is alerted that opioid medication is contra-indicated but there’s no medication in the displayed list that would be contra-indicated. The specialist suspects that there may be a masked sensitive medication, so the specialist decides to “break the glass”. The EHR Viewer presents the CDS alert that Amy’s masked anti-anxiety medication is what triggered the adverse drug-drug interaction alert, and recommends an alternative non-opioid medication.
HSPC Sand box mockup of EHR Viewer
with Clinical Decision Support app
FHIR Security Labels, Consent
Smart of FHIR OAuth 2.0
Data Interoperability Platform:
● Create a persona for Amy pre-loaded with historical data
● Accept/retrieve new data from multiple sources
● Transform raw data to FHIR if needed
● Aggregate data with historical data as part of the longitudinal history for Betty
● Resolve patient identity and terminology inconsistencies and mismatches
● Tag data with security labels so it can be processed for consent based filtering and redaction
● Evaluate data against CDS sources if needed to derive knowledge
● Expose data through FHIR APIs to consumers
● Filter data exposed through FHIR APIs based on patient defined consent provisions
● Manage and enforce authentication and authorization to the longitudinal record from external data consumers
● Manage the care plan once created to maintain the relationships between the initial care plan and additional care plans created by other care team members (in development)
● Manage the communications with the care team members (in development)
● Manage the events notifications to care team members as new data becomes available for Betty (in development)
● Deliver a patient facing UI for defining patient consent provisions
● Deliver a general purpose longitudinal record viewer to demonstrate the step-wise evolution of the longitudinal record as different care members contribute data based on the care plan (this can be unbranded for the showcase)
Note: as part of this hub and spoke architecture created for this use case, HealthConcourse will be involved after every step of the patient journey across the different encounters with care team members. However, the general purpose viewer can be unbranded and shown by each participating vendor as part of their portion of the demo so that Perspecta products do not receive more exposure to the audience then other products. Perspecta can provide the final demo for the audience to describe how the platform pulled data and care plans together along the way.
FHIR, CDS Hooks, Terminology standards (SNOMED, LOINC, RXNorm, etc.)