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To Join our track during the connectathon please use the Whova link sent to your email. There you will find access to the care coordination track zoom. Whova is only compatible with google chrome * Contact the track Lead on Zulip with any questions https://chat.fhir.org/#narrow/stream/220328-Care-Plan.2FCare.20Coordination 

Click here to sign up for Care Coordination track participation and fill out the HL7 Survey

Track overview

Short Description

This track will be hosted by the eCare Plan for individuals with Multiple Chronic Conditions (MCC) Project to test the MCC eCare plan FHIR IG and SMART on FHIR App. This is the first time the IG will be tested at a connectathon. The project plans to test participate in 6 more connectathons and ballot in 2022. The Chronic Conditions that the IG will focus on exchanging data for is Chronic Kidney Disease (tested at connectathon 1-7) Congestive Health Failure, Type 2 Diabetes, and Chronic plan ( tested at connectathon 2-7).

Long Description

What’s the purpose of hosting this connectathon track?

What do you hope to achieve?

  • Demonstrate patient and person-level information exchange across acute, ambulatory, post-acute care settings, community-based organizations, and patient digital mobile devices. 
  • Create an opportunity to explore alignment across multiple care planning IG development projects.
  • Show information exchange that addresses these challenges:
    • Coordination across multi-disciplinary provider groups
    • Not able to see big picture ‘care plan’
    • The role of the "empowered patient" with a System Actor under the individual's control

Type

  • Test an Implementation Guide

Table of Contents

What is the Care Coordination Track

The Care Coordination track focuses on patient and person-level information exchange across acute, ambulatory, post-acute care settings, community-based organizations, and patient digital mobile devices with the goal of generating, sharing and updating an electronic care plan to support multiple chronic conditions (MCC).  Care coordination helps facilitate the appropriate and efficient delivery of health care services both within and across clinical and non-clinical systems.  Care coordination activities align with and support other areas of care, such as the following:


Submitting WG/Project/Implementer Group

This track will be hosted by the Multiple Chronic Conditions (MCC) electronic Care Plan Project in collaboration with implementer communities testing several other FHIR IGs focus on and relevant to care coordination, including: 

  • HL7 FHIR Gravity Social Determinants of Health in the Clinical Care Setting (sdoh-cc)
  • PACIO Functional Status Assessment IG and Cognitive Status Assessment IG
  • HL7 FHIR Electronic Long-Term Services and Supports (eLTSS)
  • IHE Dynamic Care Planning
  • HL7 FHIR Bidirectional Service Request (BSeR) IG
  • Clinical Practice Guidelines (CPG)
  • CDS Hooks, on-patient-view
  • SMART on FHIR
  • US Core

FHIR Version

This track will use R4 version of FHIR.

Specification(s) this track uses

Artifacts of focus

Clinical input requested (if any)

Does your track have a need for input from the clinical community? If so, what are the needs?

  • Health and social services integration within a clinical care setting
  • Hoping for support and participation from EHR actors
  • Need assistance with populating certain scenario information into the EHR sandboxes


Track Leads


Expected participants

Connectathon attendance sheet

  • Jenna Norton- NIDDK MCC
  • Arlene Bierman - AHRQ MCC
  • Gay Dolin - Namaste MCC
  • Tom Hicke- Cognitive MCC
  • Joe Bormel- Cognitive MCC
  • Jerry Goodnough - Saperi Systems MCC
  • Evelyn Gallego EMI MCC
  • Katiya Shell EMI MCC
  • Dan Vreeman - RTI MCC
  • Lisa Nelson - Max MD MCC
  • Nancy Lush, Patient Centric Solutions 
  • David Hill, MITRE, PACIO-eLTSS
  • Becky Gradl - Academy of Nutrition and Dietetics

  • Margaret Dittlof - Academy of Nutrition and Dietetics


Zulip stream

Participants can follow the Zulip chat: https://chat.fhir.org/#narrow/stream/220328-Care-Plan.2FCare.20Coordination for relevant information


HL7 Connectathon 25 Track Schedule September 9-11

Track orientation meeting material  and schedule for HL7 Connectathon 25

Date

Planned activities- See detailed schedule here

Meeting Materials

September 4, 2020

Post the HL7 Track orientation slide deck and schedule

September 9, 2020

4:00 PM HL7 Connectathon kick-off


September 10, 2020

9:00 Care Coordination Track Kick Off

10:00-1:00 Test scenario 1-4

2:00-5:00 Test  scenario 5-8

5:00-6:00 Lessons Learned



September 11, 2020

9:30 -11:00Test Bonus Scenario

  • Bonus 1 Scene 5 CognitiveQuestionnaire
  • Bonus 2 Scenario 9 Retrieve Patient's Dietitian Referral (BSeR)
  • Bonus 3 Care Management/ CPG



Track Prep Meetings Prior to connectathon

The track conducted weekly meetings starting in the month of August to prep for the connectathon. The information below can serve as educational materials.  


System Roles

Describe each type of system that could participate in the track. The participants/organizations that will play these roles will be updated

Actor

Role

Participant Name/ Organization

1

PMEHR (PCP)


1

Provider App

MMC SMART on FHIR App

2

Patient App

Max MD, Patient Centric Solutions, Patient Link Enterprises

Please include information here regarding how much advance preparation will be required if creating a client and/or server.

Ωenarios

Please go to this link to see the GET statements for the scenarios below

Test Scripts

GITHUB: Connectathon Demo Data and scripts for loading resources

Security and Privacy Considerations

Please contact track lead to learn more about the connectivity requirement for the Hub

For all scenarios the FHIR server is referenced by {ServerBase}.

There is an open logica fhir server at: https://api.logicahealth.org/MCCeCarePlanTest/open/metadata

Secure Server end point https://api.logicahealth.org/MCCeCarePlanTest/data

General Data:

Field

Value

subject-id

cc-pat-pnoelle

patient-name

Patricia Noelle

ckd-careplan-id

cc-careplan-pnoelle-ckd

Serverhttps://api.logicahealth.org/MCCeCarePlanTest/open/
Secure Serverhttps://api.logicahealth.org/MCCeCarePlanTest/data

MCC IG US Core Patient Example: 

Scenario 1: Retrieve Patient’s Chronic Kidney Disease Care Plan from an EHR

Profile

Data Element

Sample Data

Code

Chronic Kidney Disease Care Plan

CarePlan.addresses:SliceChronicKidneyDisease

Patient has chronic kidney disease (CKD) and has a CKD Care Plan in the reference EHR

SNOMED CT:

709044004 Chronic kidney disease (disorder)

Action: A Client calls the EHR server to request a CKD focused MCC care plan from the Server

Precondition: Patient and Care Plan exist on server.

Success Criteria: The Client receives the care plan as expected based on the in parameters provided to the server and successfully displays the data

Bonus Point: Query using MCC Chronic Condition Value Set (2.16.840.1.113762.1.4.1222.159)

Basic Query Flow: 

  1. Find the Condition for the patient matching the CKD 
  2. Find CarePlans that address this Condition

Basic Query - By Steps:  

  1. {Server}/Condition?subject={subject-id}&code=709044004
  2. Extract condition-id (i.e. Condition id, e.g cc-cond-pnoelle-ckd)
  3. {Serve}}/CarePlan?condition={condition-id}
  4. Extract the Care plan id as careplan-id

Example: 

  1. GET https://api.logicahealth.org/MCCeCarePlanTest/open/Condition?subject=cc-pat-pnoelle&code=709044004
  2. GET https://api.logicahealth.org/MCCeCarePlanTest/open/CarePlan?condition=cc-cond-pnoelle-ckd

Basic Query - Chained:  

  1. GET {Server}/CarePlan?subject={subject-id}&condition:Condition.code=709044004

Bonus Query:  (Not working on our test server)

  1. {Server}/Condition?subject=cc-pat-pnoelle&code:in=2.16.840.1.113762.1.4.1222.159
  2. Extract condition-id (i.e. Condition id, e.g cc-cond-pnoelle-ckd)
  3. {Server}/CarePlan?condition={{condition-id}}
  4. Extract the Care plan id as careplan-id

As Chained Query:

  1. GET {Server}/CarePlan?subject={subject-id}&condition:Condition.code:in=2.16.840.1.113762.1.4.1222.159



Scenario 2: Update Client MCC CKD Care Plan CKD Condition (Health Concern) Supporting information from CKD stage 3 to CKD Stage 4

Profile

Data Element

Sample Data

Code or URL

Chronic Kidney Disease Care Plan

CarePlan.supportingInfo.Condition.ChronicKidneyDiseaseCondition

Patient has chronic kidney disease (CKD) condition profile instance in client Care Plan  

MCC Chronic Kidney Disease Profile

http://hl7.org/fhir/us/mcc/StructureDefinition/

ChronicKidneyDisease

https://trifolia-fhir-dev.lantanagroup.com/igs/lantana_prod_hapi_r4/MCC-IG/StructureDefinition-ChronicKidneyDisease.html

See example: https://trifolia-fhir-dev.lantanagroup.com/igs/lantana_prod_hapi_r4/MCC-IG/Condition-f202.html

Existing:

ChronicKidneyDiseaseCondition

Condition.code

Chronic kidney disease stage 3 (disorder)

433144002

Update:

ChronicKidneyDiseaseCondition

Condition.code

Chronic kidney disease stage 4 (disorder)

431857002

Action: A Client calls the EHR server to request for (CKD Condition) updates within CKD focused MCC care plan and/or from the EHR Server Problem List

Precondition: Patient and Care Plan exist on server. Problem list (or encounter occurred(??)) where a CKD Stage 4 Condition/Problem was added to the Problem list or added as Health Concern to Care Plan in an EHR Care Plan.

  •         Note: ChronicKidneyDiseaseCondition (stage 3) has Condition.abatement.DateTime that equals the ChronicKidneyDiseaseCondition (stage 4) Condition.onset.dateTime

Success Criteria: The Client receives the added stage 4 CKD problem as expected based on the in parameters provided to the server and successfully displays the updated data

Process flow:

  1. Fix-up existing CarePlan addresses by code 709044004 (Bundle Scenario_2_setup_bundle.json) Adds Stage 3, Updates CarePlan, inactivate prior CKD,
  2. (GET) Retrieve CarePlan addressing stage 3(e.g. GET {{Server}}/CarePlan?subject={subject-id}&condition:Condition.code=433144002)
  3. (PUT/POST) Add Stage 4 Condition
  4. (PUT) Update Addresses Stage 4, and add Stage 3 to Supporting Info
  5. (GET) Retrieve CarePlan addressing stage 4(e.g. GET {{Server}}/CarePlan?subject={subject-id}&condition:Condition.code=431857002)

Specific Resource Bundles:

FileDescription
scenaro_2_setup_bundle.json

Transaction Bundle that will setup the scenario. The Stage 3 Condition is added, the general condition is marked inactive, and the care plan is updated to address type 3 CKD and the prior condition is places as supporting info. We think there must be a better was to update the status to indicate progression, but none was found in time for the Connectathon.

scenaro_2_stage4_bundle.jsonTransaction bundle that will care out stage 3/4 of the process flow. The stage 4 CKD is added, the stage 3 is mark as inactive, the CarePlan is updated have stage 3 and supporting info and address stage 4.
scenaro_2_reset_bundle.jsonResets the State to before - Removes Stage 3 & 4 and resets CarePlan

 Bonus Point: NA (Note, for the NEXT connectathon we could test querying for stage in condition.stage vs as precoordinated code

 

 Scenario 3: Retrieve patient CKD relevant labs from EHR

Profile

Data Element

Sample Data

Code or URL

EstimatedGlomerularFiltrationRate

CarePlan.supportingInfo.USCoreLaboratoryObservationProfile

Glomerular filtration rate/1.73 sq M.predicted among females [Volume Rate/Area] in Serum, Plasma or Blood by Creatinine-based formula (MDRD)

·          

 

http://hl7.org/fhir/us/mcc/StructureDefinition/EstimatedGlomerularFiltrationRate

 

50044-7

 

http://hl7.org/fhir/us/mcc/StructureDefinition/EstimatedGlomerularFiltrationRate
or
https://trifolia-fhir-dev.lantanagroup.com/igs/lantana_prod_hapi_r4/MCC-IG/StructureDefinition-EstimatedGlomerularFiltrationRate.html

See example:https://trifolia-fhir-dev.lantanagroup.com/igs/lantana_prod_hapi_r4/MCC-IG/Observation-EstimatedGFR.html

 

SerumCreatinine

CarePlan.supportingInfo.USCoreLaboratoryObservationProfile

Creatinine [Mass/volume] in Serum or Plasma

http://hl7.org/fhir/us/mcc/StructureDefinition/SerumCreatinine

or

https://trifolia-fhir-dev.lantanagroup.com/igs/lantana_prod_hapi_r4/MCC-IG/StructureDefinition-SerumCreatinine.html


See example:

 https://trifolia-fhir-dev.lantanagroup.com/igs/lantana_prod_hapi_r4/MCC-IG/Observation-SerumCreatinine.html

2160-0  

 Action: A Client calls the EHR server to request for chronic pain conditions for EHR Problem list (or encounter documentation (??)).

Precondition: The lab observations exists in the EHR server

Success Criteria: The Client receives the Observations from EHR server


  •  GET {Server}/Observation?subject={subject-id}&code=50044-7

  •  GET {Server}/Observation?subject={subject-id}&code=2160-0 

 

Scenario 4:   Retrieve MedicationStatement or MedicationRequest - BONUS

 Action: 

  1. Fetch Active  Medications for Subject 
  2. Fetch Med associated with CarePlan 
  3. Fetch Active Medication Statement

Precondition: TBD

Success Criteria: TBD

Bonus Point: NA

 

 Scenario 5: Retrieve QuestionnaireResponse for pain perception from EHR

Profile

Data Element

Sample Data

Code or URL

ChronicPainConditions

CarePlan.supportingInfo.QuestionnaireResponse.PainPerception

Patient has completed a pain perception Questionnaire in the EHR and QuestionnaireResponse is available


LOINC 38212-7 Pain assessment panel

https://loinc.org/75259-2/

 Action: A Client calls the EHR server to request for chronic pain conditions for EHR Problem list (or encounter documentation (??)).

Precondition: A completed lHC Form for https://loinc.org/75259-2/ exists in the EHR server

Success Criteria: The Client receives the completed FHIR R4 Compliant QuestionnaireResponse from EHR server

Bonus Point: Contain Pain perception QuestionnaireResponse on CarePlan.supportingInfo.Condition.ChronicPainConditon in Condition.evidence.detail (QuestionnaireResponseResource)

      GET {Server}/Observation?subject=cc-pat-pnoelle&code=38212-7

 Options:  use QuestionnaireResponse resource or Observation Derived from a QuestionaireResponse

Main

  1. Fetch from Right Questionnaire Response
  2. Add Condition based Questionnaire 

Bonus

  1. Scan Questionnaire for Correct Item
  2. Fetch Response
  3. Get Right Item

 

 Scenario 6: Retrieve Patient’s Chronic Pain Condition from EHR and add to Client MCC Care Plan

Profile

Data Element

Sample Data

Code

ChronicPainConditions

CarePlan.supportingInfo.Condition.ChronicPainCondition

Patient has chronic pain on EHR Problem list or in EHR Care Plan


Chronic pain condition is retrieved: 

https://trifolia-fhir-dev.lantanagroup.com/igs/lantana_prod_hapi_r4/MCC-IG/StructureDefinition-ChronicPainConditions.html

Chronic Pain: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1222.76/expansion/Latest

SNOMED CT:

102481003 Generalized chronic body pains (finding)

Action: A Client calls the EHR server to request for chronic pain conditions for EHR Problem list (or encounter documentation (??)).

Precondition: A chronic pain condition has been added to the problem list in the EHR

Success Criteria: The Client receives the chronic pain condition (profile instance) as expected based on the in parameters provided to the server and successfully displays the data

Bonus Point: Contain Pain perception QuestionnaireResponse on CarePlan.supportingInfo.Condition.ChronicPainConditon in Condition.evidence.detail (QuestionnaireResponseResource)

  •        GET {Server)}Observation?subject=cc-pat-pnoelle&code=102481003

 

Scenario 7: Retrieve Patient’s Weight observation from EHR and add to Client MCC Care Plan

Profile

Data Element

Sample Data

Code or URL

BodyWeight (CIMI)

CarePlan.supportingInfo.Observation.ChronicPainConditon

Patient has body weight observation in EHR

http://hl7.org/fhir/us/vitals/StructureDefinition/BodyWeight.observation.code.code =29463-7

Action: A Client calls the EHR server to request for a body weight observation.

Precondition: A body weight observation has been added in the EHR

Success Criteria: The Client receives the body weight observation (profile instance) as expected based on the in parameters provided to the server and successfully displays the data

Bonus Point: NA

  •          GET {Server)}Observation/?subject=cc-pat-pnoelle&code=29463-7

 

 Scenario 8: Retrieve Patient’s Weight Goal from EHR and add to Client MCC Care Plan

Profile

Data Element

Sample Data

Code or URL

Body Weight Target (Goal)

BodyWeightTargethttp://hl7.org/fhir/us/mcc/StructureDefinition/BodyWeightTarget

29463-7

Body weight

 

Lose 10 pounds in 3 months

Action: A Client calls the EHR server to request for a patient weight goal

Precondition: A patient weight goal has been added to the EHR Care Plan

Success Criteria: The Client receives the weight goal (profile instance) as expected based on the in parameters provided to the server and successfully displays the data

  • GET {Server)/Goal/?subject=cc-pat-pnoelle
  • Search Targets of each goal since target is not a search parameter (Issue)

Bonus Point: NA

 

Scenario 9: Retrieve Patient’s Dietitian Referral (BSeR) - BONUS

Specific BSeR Profile used within the MCC Care Plan:

http://hl7.org/fhir/us/bser/STU1/StructureDefinition-BSeR-ReferralServiceRequest.html

Profile

Data Element

Sample Data

Code or URL

BSeR_ReferralServiceRequest

CarePlan.Activity.reference.BSeRRefferalServiceRequest

ServiceRequest.Category: SNOMED: 409063005 | Counseling (procedure) 

ServiceRequest.code:

 bound

value

set

which

is

"extensible":

https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1099.45/expansion/Latest

Use this code: 

http://hl7.org/fhir/us/bser/StructureDefinition/BSeR-ReferralServiceRequest

Action: A Client calls the EHR server to request for a dietitian referral OR referral is created and sent

Precondition:  Referral exists or can be created and sent in EHR

Success Criteria: Referral is retrieved and can be seen in Care Plan

Bonus Point: NA

  •         GET TBD