Cross-Paradigm_Story_Board_Artifact:_Payer_Perspective_Value-Based_Care

 

 

Project Insight: 1347

 

HL7-International-Logo_2_x2

 

 

 

Cross-Paradigm Story Board Artifact: Payer Perspective, Value-Based Care, Release 1

(US Realm)

 

HL7 Informative Ballot

May 2018

 

Sponsored by:

Attachments Work Group

Co-Sponsored by:

Financial Management, Clinical Decision Support, and Clinical Quality Information

 

Copyright © 2016 Health Level Seven International ® ALL RIGHTS RESERVED. The reproduction of this material in any form is strictly forbidden without the written permission of the publisher.  HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. Pat & TM Off.

Use of this material is governed by HL7's IP Compliance Policy .


Structure of This Guide

This informative guide includes the pdf document describing the story board and the approach used to create it.  The appendices include narrative synthetic data supporting the story details.  Additional synthetic C-CDA files are included with the package to represent data generated and shared over the course of care depicted in the story board.


Acknowledgments

This story board was developed through participation of many HL7 Work Group members and other resources from the payer community and patient advocate community.

Participating Organization

BCBSA

Lead Participant Name

e-mail

Lenel James

Lenel.James@bcbsa.com

Lead Participant Name

e-mail

Lisa Nelson

LisaRNelson@cox.net

Team members

 

Name

Title

e-mail

Amal Agarwal, MD

Payer

AAgarwal31@payer.com

Name

Title

e-mail

Patrick Murta

Payer

pmurta@payer.com

Name

Title

e-mail

Jackie Hardison

Payer HealthIT Manager

jhardison@payer.com

Name

Title

e-mail

Derek Mydlarz, MD

Payer

dMydlarz@payer.com

Name

Title

e-mail

Gowtham Roa, MD

Chief Medical Information Officer

Gowtham.Rao@bcbssc.com

Name

Title

e-mail

Andrea Gelzer, MD

SVP and Medical Officer

AGelzer@amerihealthCaritas.com

Name

Title

e-mail

Tom Simmer, MD

SVP & Chief Medical Officer

TSimmer@bcbsm.com

Name

Title

e-mail

Lynda McMillin

eHealth & EDI Manager

LMcMillin@bcbsm.com

Name

Title

e-mail

Charles DeShazer, MD

SVP & Chief Medical Officer

Charles.DeShazer@highmark.com

Name

Title

e-mail

Dennis Brinley

Health IT & FHIR Lead, Sr. Architect

Dennis.Brinley@highmark.com

Name

Title

e-mail

Van Ly

Sr. Director

Van.Ly@njii.com

Name

Title

e-mail

Thomas Ortiz, MD, FAAFP,

Medical Director, NJII

thomasrortizmd@gmail.com

Name

Title

e-mail

Lisa R. Nelson

Founder, Janie Appleseed Network

LNelson@JanieAppleseed.org

 



Key Storyboard Objectives

The Storyboard artifact describes a patient-centered situation that includes relevant value-based care challenges from the payer perspective. It addresses four key objectives:

  1. Versioning . The story describes a scenario that demonstrates challenges to be addressed when the systems involved in data exchange are operating on different versions of base standards such as FHIR and C-CDA. It helps payers examine the operational impact of systems supporting different versions of the standards.
  2. Emerging Value-Based Care Models . The story demonstrates envisioned value-based care practices. It helps payers communicate their view of what care delivery looks like under value-based care, as payers begin to offer more services that put their employees into functions that are part of the patient’s care team.
  3. Quality Measurement and Clinical Decision Support . The story includes scenarios covered by existing quality measures (for example, the HEDIS measures for Adult BMI Assessment, Controlling Blood Pressure, and Breast Cancer Screening). It demonstrates envisioned changes that help to reduce clinician burden around quality measurement and shows the importance of accurate clinical documentation to support more efficient information gathering to support quality assessment. It also demonstrates techniques that use population health strategies to improve care for individuals within those populations. Clinical details in the story support quality reporting computation and clinical decision support mechanisms. The objective is for the story to help find ways to reduce the burden of quality measurement and improve the quality of care.
  4. Care Planning . The story shows care plan information being created and shared in addition to care summary information. Care Plan information identifies the concerns, goals, and interventions planned to address those goals.  Care Summary information describes care that has been given. It documents services provided and interventions performed during a care encounter or a set of encounters over a range of time. It helps payers express their vision for how care planning will be done in the future to support value-based care. It demonstrates envisioned care team coordination and collaboration to reduce gaps in care while reducing the cost of care. It also demonstrates envisioned increases in patient and family engagement as a means of improving care outcomes and decreasing the cost of care.

 

All aspects of the story are not covered at the same depth of detail. Areas of the story that are relevant to the four prime objectives include more detail and other areas include less.

Synthetic data is used where possible to create identity information for patients, providers, and organizations in the story. Patient demographics and medical history information is developed using synthetic data and other fabricated details developed solely for the purpose of meeting objectives for the storyboard.

The specific care pathways were developed using clinical resources participating in the project.  The collaboration was organized using asynchronous inputs through a formalized template that enabled the contributions of many participants to be synthesized together for an optimal result.

The care pathways developed for the storyboard are realistic. However, the priority was for the course of care to include challenges that demonstrate issues pertinent to payer’s concerns and perspectives. The goal of the storyboard is not to teach clinical care practices nor is it to suggest best practice for treating a particular illness or condition.  While the storyboard aims to include clinical details that are relevant and sufficiently accurate, the goal for the story is to meet the four key objectives enumerated above.

As a result of this careful and prescriptive approach to the development of the scenario, this storyboard provides a data-rich environment for examining and discussing various technical solutions with greater clarity in the context of more realistic scenarios.

Approach to Creation and Future Use

This cross-paradigm storyboard was created by gathering clinical input from multiple resources representing a diverse group of payers. Each participating payer group contributed to the creation of the storyboard by following a similar process, which included the following steps. Participants contributed where they had experience, knowledge, and vision to lend. It was a collaborative effort that produced a future-oriented consensus view of what value-based care may look like in the future, from a payer’s perspective.

Step 1.  Reviewed and Edited the High-Level Story Summary

Participants made improvements or clarifications that seemed needed to position the story to address the key objectives of the storyboard. They added notes or comments in the column on the right to show when the story was tied to showing one of the key objectives. 

Step 2. Reviewed and Edited the Narrative Story

Participants made improvements or clarifications that seem needed to cover the key objectives for the storyboard. They revised the high-level story as needed, given the changes introduced in this step.

Step 3. Added Temporal and Care Team Member Details

Participants revised the narrative story to add temporal details to enrich the precision of the information depicting the journey.  They made sure all storyboard actors were identified in the summary, including individuals, organizations, and other system actors. They created synthetic data to identify salient demographic information required to identify the actors.

Step 4. Added Synthetic Clinical Data

Where possible, clinical data was generated and recorded in the form of narrative HL7 C-CDA R2.1 documents.  Over time, it is envisioned that HL7 community using the storyboard will add the associated discrete data needed to test technical solutions.

Step 5. HL7 Balloting and Reconciliation, Publishing

The HL7 ballot process was used to enable a larger community to comment and contribute ideas for needed revisions before publication as an informative resource.

Step 6. Future Use

It is envisioned that the storyboard could be updated by others to address additional objectives and include more clinical details to support those objectives. The update process would follow HL7’s processes for introducing and publishing updates to a standards artifact. It also is envisioned that this storyboard could be used to spawn other storyboards, covering a different care pathway or a different set of clinical assumptions about the people, the care team members involved in care, or the events that unfold within the story.  As the number of cross-paradigm storyboard artifacts grows, it also is envisioned that HL7 will need to devise a categorizing and cataloging system to differentiate and organize versions and variations of published storyboards.

 

High-Level Story

Background

The storyboard is about a family. One member of the family is dealing with type 2 diabetes, a common situation facing many families today.

 

It covers a 12-month period between January 1, and December 31. The care events are depicted within one calendar year to reduce complexity when it comes to address the quality measurement objectives. The year is omitted from the story so that any year can be used.

 

The story board is intended to drive innovation and technology improvement. The HIT technology utilized in the story is not limited to technology that has been available in the past. Technical details specifying how the technology works are “foreshortened” in the perspective taken for the story board, making it possible for that aspect of the story to become visible as the storyboard is used across different standards paradigms.

 

The storyboard is visionary. It reflects the way payers envision care delivery will work in the future when value-based care models are operational.

 

The storyboard encompasses multiple care encounters, in multiple cities, across two regional HIEs and one out-of-state HIE. This complexity is important to demonstrate the challenge of information exchange across disparate systems controlled by different organizations and operating under different business practices and policies.

 

The storyboard actors include the patients (a husband and wife), two different payers and their representatives who support members and several care providers across two different states. The care management roles played in each scenario differ because care providers organize and run their care practices differently and employer’s benefit plans offer different levels of care management and disease management for members.

 

The storyboard introduces care planning roles and new care management processes, emerging to support the shift to value-based case. The concepts of care management, disease management, and case management, are defined below as well as the roles of Care Manager, Disease Manager, and Case Manager. As new operating models emerge to support Patient Centered Medical Homes and Accountable Care Organizations, the division of responsibilities for care management, disease management, and case management, may be shared differently between payers and care providers.

 

The storyboard includes two different examples to demonstrate that differences in the responsibility for these roles needs to be taken into consideration when planning for interoperability.

 

In Sofia’s situation, she receives her primary care from a practice that operates as a Patient Centered Medical Home (PCMH). The health benefit plan from her employer includes disease and case Management services to help patients navigate the health system and support their care. Sofia had previously elected to be enrolled in this program after several trips to the Emergency Room and a diagnosis showing her diabetes was not well-controlled. Enrolling in the program enables her clinical information to be shared with individuals providing disease and case management services that help Sofia better manage her chronic conditions at a lower cost.

 

A PCMH is a practice that has been recognized by a national quality assurance organization, i.e. NCQA, after a rigorous review of practice principles of practice, policy and procedure and ability to tract patient personal health data.

A PCMH follows a model of care that puts patients at the forefront of care. PCMH recognition programs are designed to improve patient care, lower costs, and align with Payers. PCMHs build better relationships between people and their clinical care teams. Research shows that they improve quality, the patient experience and staff satisfaction, while reducing health care costs.

NCQA’s Patient-Centered Medical Home Recognition Program is the most widely adopted Patient-Centered Medical Home evaluation program in the country. More than 12,000 practices (with more than 60,000 clinicians) are recognized by NCQA. And more than 100 payers support NCQA recognition through financial incentives or coaching.

When a practice earns recognition through NCQA, it means the practice has made a commitment to providing quality improvements in care and to offering a patient-centered approach to care that results in patients that are happier and healthier.

In Samuel’s situation, he sees a PCP at a practice that is part of an Accountable Care Organization (ACO). The ACO contracts with the practice to provide Care Management services for patients who benefit from the additional support and care coordination.

 

An ACO is a group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients. An ACO is an organization that contracts with payers on behalf of the providers. They may share risk for the coverage of the patient’s care.

 

The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it shares in the savings it achieves for the Medicare program.

 

 

Introduction

Notes/input

Proposed Story Content

 

Samuel and Sofia Mateo are a married couple who live in Pittsburgh, PA. They have one grown daughter who is married with two children and lives in Michigan near where Samuel’s elderly mother still resides.

 

 

Samuel was born on January 2. Sofia was born on February 1.  He turns 59 and she turns 57 during the year of this story.

 

Set up for objective 3

Samuel and Sofia have been smokers since they were teenagers. They have tried to quit several times, but never stopped completely.

 

They have not been very engaged in worrying about their diet, exercise, weight or other health-related issues.  Neither of them felt the need to be doing expensive screenings such as mammograms or colonoscopies since they were not experiencing major health issues. Sofia had done a mammogram when she first turned 40 but found the test to be very uncomfortable and has avoided doing any subsequent breast cancer screening. Neither of them opted to get a colonoscopy when then turned 50. They don’t get flu shots and in general have tried to minimize going to the doctor over the course of their lives.

 

Set-up for objectives 2 and 4.

Sofia and Samuel have different health insurance plans. Sofia works for ABC, Inc. and her health insurance plan is a family plan through Payer #1.  Sofia’s plan includes a special program that offers members with multiple chronic conditions additional support, when needed, to optimize the care and improve health outcomes. Her plan provides secondary coverage for Samuel. Samuel works for XYZ Co. and his health insurance plan is through Payer #2.  His plan also is a family plan and provides secondary coverage to Sofia.

 

Set-up for objectives 2, 3 and 4

 

Issue: it is challenging for care organizations to know when a person has access to care management services through his or her health plan.

 

 

 

 

 

 

 

 

 

 

 

 

 

Set up for objectives 3 and 4.

 

 

 

 

Set up for objective 1.

Sofia has multiple health conditions. She developed asthma as a child but controls it with medication and an inhaler. She was diagnosed with adult Type-2 diabetes two years ago and was put on medication to help control her blood sugar.

 

Sofia’s health plan includes disease management services and after she was diagnosed with diabetes, she was enrolled in a program to provide additional support for her diabetes.  Sofia is contacted from time to time to check on her progress, address concerns she may have about her condition, and remind her of activities she can participate in to help manage her conditions. She received education on how to check her sugar-levels and monitors them regularly. Sofia is engaged in the care plan her care team has developed for her.

 

Last year, Sofia joined a local gym and began working with a nutritionist. She began exercising regularly and started watching her weight. She lost over 50 pounds during that year. Sofia also has a care plan to remind her of any upcoming appointments and to track her personal exercise goals.

 

During the prior year, Sofia’s PCMH began reaching out to its patients who had not had a mammogram in the past year. Sofia got a call from a nurse who listened to Sofia’s concerns about the pain associated with the test and explained the benefits and offered some suggestions for dealing with the discomfort. Sofia agreed to do the mammogram at the end of December. The results of the screening triggered Sofia to get a diagnostic ultrasound in the beginning of January which produces additional evidence suggesting breast cancer. The Disease Manager covering Sofia’s diabetes and asthma care engages a Case Manager to follow Sofia’s complex care needs as a result of her cancer treatment needs.

 

Sofia elects to have her breast surgery done in Philadelphia by the surgeon who took care of her sister’s breast cancer last year.

 

Set-up for objective 3.

 

 

 

 

 

Set-up for objectives 2 and 4.

 

 

 

 

 

 

 

 

 

 

 

Set up for objective 1.

Issue: It is challenging for HIE’s to gather and forward information about patients who are not known to the HIE. Identity matching processes may not handle unknown people as needed to support this story board.  Sharing information between HIE’s will need to address version differences in the technology deployed in the various environments.

Set-up for objective 3

Samuel has not had any major health issues over the course of his lifetime thus far. His weight has increased gradually over time, especially after turning 40. He tried to quit smoking after his daughter was born but did not succeed.  Samuel has rarely gone to the doctor.

 

Samuel’s employer changed insurance plans last year. Samuel’s new PCP is part of an Accountable Care Organization. The ACO contracts with the PCP’s practice to provide care management for its patients. Samuel saw his new PCP for the first time, last fall. They discussed the benefits of colorectal cancer screening, but Samuel was convinced he wanted to have the test. The ACO established a care plan for Samuel to remind him of any upcoming appointments and track his personal health goals. The plan included a section at the bottom that noted some care quality issues for Samuel to consider. It showed a set of quality measures and indicated if Samuel was compliant to these best practices or not.

 

During the year of the story, Samuel fractures his wrist while visiting family in Michigan. His initial care is provided in an Emergency Department in Michigan. The Care Manager from his PCP’s office is engaged by the ED team to help make sure Samuel gets the follow-up care he needs once he gets back to Pittsburg. She makes sure the right resources within the ACO receive the right information to ensure effective continuity of care for Samuel after his return home from Michigan.

 

Samuel’s situation becomes a concern for Sofia because he can’t drive for a couple weeks while Sofia is having heavy chemo.  Sofia’s Payer Case Manager helps to coordinate support services for Sofia while Samuel is recovering from his wrist fracture.

 

Set-up for objective 3

As the year comes to a close Sofia’s care transitions back to her PCP. Samuel chooses to work more closely with his ACO care team and begins to address some of the places where he was not following guidelines for optimal health outcomes.


Detailed Narrative and Timeline - Sofia [KC1] [JL2] [KC3]

Event

Date

Proposed Content

Synthetic Data

1

October 18, two years ago

Sofia saw a different doctor for her annual exam in October two years ago.  She downloaded a CCD from the Patient Portal just after her appointment [KC4] , as the view, download and transmit [JL5] feature of Blue Button from the doctor, as an available feature of the doctor ’s EHR .

 

20151018 H&P Document

2

October 15, last year

Sofia saw a new PCP, Patricia Primary, whose office is just down the street from her home .  Since Sofia d islikes   oesn’t driv ing e , she felt it would be easier to get to her appointments.  [KC6] PCP orders lab work and orders a mammogram. (Lab results are returned via an established HL7 V2 Lab Results interface.) PCP orders a Nutrition Consultation.

20161014 CCD Document

20161015 H&P Document

20161015 Referral Note

20161015 Care Plan-PCP

20161015 CCD Document

3

October 27, last year

Sofia has a visit with the Nutritionist at her PCP’s practice.  The Nutritionist puts Sofia on a low salt, 1500 calorie ADA diet, increases water intake, and sets a goal of a 10-pound weight loss in 4 months. [KC7]

20161027 Progress Note

20161027 Care Plan-PCP

4

November 15, last year

Nurse from the ACO has been monitoring patients who have not received their annual mammogram. She called Sofia to book an appointment.  Sofia agrees.

20161115 Progress Note

20161115 Care Plan-PCP

5

December 22, last year

Sofia has her mammogram.  PCP’s office receives conformation that mammogram was performed.

20161222 Care Plan-PCP

20161222 Consultation Note

6

January 4

Sofia receives a letter from the imaging center explaining that the mammogram she had in December detected and area in her right breast that warranted additional imaging. The letter asked her to call the Woman’s Health Center where here study was performed to schedule a diagnostic ultrasound. She called right away and got an appointment for January 16th. The letter explains that the results of the mammogram have been shared with her OB/GYN and her PCP.

 

20160104 Recall Letter DI

 

7

January 16

She goes to the imaging center and gets the ultrasound mammogram and Mammotomograph [KC8] done. A Radiologist reviews the ultrasound and finds it is suspicious for breast cancer. She briefly reviews her findings to Sofia that day but explains that her results have been sent to her PCP who will be called to discuss next steps. The Radiologist follows up with a phone call to Sofia’s PCP. A Diagnostic Imaging Report and Consultation Note are sent to Sofia’s PCP.

 

20170116 DIR MAMMO TAMO

20170116 US RT BREAST

8

January 18

 

The PCP calls Sofia to discuss the results and recommends a referral to a general surgeon. Sofia agrees so the PCP sets up an appointment for her with a general surgeon for the next day. Her PCP sends the referral information to the surgeon. A copy of the referral goes to Sofia’s care team members at the health plan too.

 

20170118 Referral Note*

20170118 Care Plan-PCP*

9

January 18

Receiving a copy of the Referral Note documents, the Care Plan Management System used by Sofia’s health plan is triggered by the referrals to a surgeon. The health plan assigns a Case Manager for Sofia. The Case Manager will make sure Sofia’s complex care will be coordinated across the many clinicians who will be taking care of her condition. The Case Manager also will monitor Sofia’s care plan and make sure Sofia understands all her treatment options while addressing her breast cancer. The Case Manager contacts Sofia to see if she has any questions or concerns. Sofia explains she is scheduled to meet with the general surgeon the next day. The Case Manager sends Sofia’s PCP a request for Sofia’s current Care Plan. Sofia is copied on that request. The requested care plan information helps Sofia’s Case Manager [KC9] coordinate Sofia’s care with the rest of her care team. The Case Manager also copies Sofia on a request to receive the Procedure Note from the surgeon. The Surgeon receives that request. The PCP sends back a copy of Sofia’s care plan to the Case Manager.

 

20170118 Care Plan-Payer*

 

10

January 19

Sofia meets with the general surgeon.  A biopsy is scheduled. The surgeon sends a consultation note to Sofia’s PCP to update him about the visit with Sofia and the plan to perform the biopsy. A copy of the Consultation Note goes to the Case Manager. She sees that a procedure is scheduled to be performed, so a communicationRequest [KC10] is sent to request the Procedure Note.

 

20170119 Consultation Note*

20170119 Care Plan-PCP*

20170119 Care Plan-Payer*

20170119 DIR MRI BREAST BILATERAL

11

January 24

The general surgeon performs the biopsy at the local hospital where he has privileges. He sends a copy of the Operative Note to Sofia’s PCP and her Case Manager at the health plan (as requested on January 18th).

 

20170124 Procedure Note*

20170124 Care Plan-PCP*

20170124 Care Plan-Payer*

20170124 BREAST BIOPSY RIGHT

20170124 DIR MAMMO DIAG RIGHT

12

January 25

A tumor board reviews her case and provides a diagnosis based on the type, stage and grade of her cancer. A Pathologist participates in the review. The Pathologists report documents the findings from the Tumor board. A copy of this report is shared with Sofia’s PCP and her health plan Case Manager. [KC11]

 

20170124 Care Plan-PCP*

20170124 Care Plan-Payer*

20170125 Consultation Note*

20170125 PATHOLOOGY RPT

13

January 26

 

The PCP calls Sofia to discuss the results of the biopsy and to schedule a consultation with a Medical Oncologist. Sofia wants to wait until her husband returns from a trip. The PCP arranges an appointment for Sofia with a Medical Oncologist on the 31st. Samuel gets home from Michigan in time to participate in the meeting.

20170126 Care Plan-PCP*

14

January 31

Sofia and her husband go for a consultation with the Medical Oncologist. She brings him a detailed family history form which his office asked her to complete. He explains the recommended treatment path for her type and stage of breast cancer. He explains it would include chemotherapy, followed by a lumpectomy, and then may require radiation. He recommends genetic testing that may provide information that helps to determine the right chemotherapy course , but explains this test may require pre-authorization through her insurance company [KC12] . He provides Sofia with educational material that covers everything they reviewed.

 

20170131 Care Plan-BreastCancer*

20170131 Consultation Note*

20170131 Care Plan-PCP*

20170128 CARE TEAM

20170131 PAT EDU

15

February 1

Sofia discusses the situation with her husband and her sister, who lives in Philadelphia and just had breast cancer last year. Sofia decides she would like to have her sister’s Surgical Oncologist perform the surgery, but she would like to work with the local Medical Oncologist for the chemotherapy and radiation treatments in order to minimize the amount of driving back and forth to Philadelphia.

 

20170202 Care Plan-Payer*

16

February 2

Sofia calls the Case Manager at her health plan to talk about her preferences and see what might be possible. She also discusses the challenge with her husband’s recent wrist fracture and his not being able to drive for a couple of weeks. 

 

20170202 Care Plan-Payer*

17

February 3

Sofia’s care team has a meeting to discuss her case and her preferences and determine what will be possible.  Based on Sofia’s family history, the recommendation for genetic testing is discussed and approved under her plan coverage. The Case Manager helps the team understand Sofia’s coverage options and the cost considerations of using the breast surgeon in Philadelphia. They weigh out the options and determine it would be possible for Sofia’s surgery to be performed in Philadelphia. The team agrees on the plan. The Medical Oncologist does a referral to the surgeon in Philadelphia so that he can begin to follow Sofia’s progress during her chemotherapy and stay informed about the case in preparation for the surgery.

 

20170203 Care Plan-Payer*

20170203 Care Plan-MedOnc*

20170203 Care Plan-PCP*

 

20170204 Referral Note*

 

18

February 6

Sofia begins 6 months of chemotherapy under the care of her Medical Oncologist.  The genetic testing data is considered when selecting the therapy. The plan is for Sofia to go to his office every other week for heavy treatments in the first two months, then shift to lighter but more frequent treatments once per week for the remaining 4 months.

 

20170206 Care Plan-MedOnc*

20170206 Consultation Note*

20170205 GEN TEST LETER

20170205 GEN TEST RESULTS

19

February 6-24

During the first few weeks of Sofia’s chemo treatment, Samuel is unable to drive due to his wrist fracture and less able to care for Sofia. The Case Manager at Sofia’s health plan helps arrange transportation services for Sofia and some in-home support for meals and light housework.

 

Sofia’s Medical Oncologist orders lab tests for bloodwork to be done weekly while the chemo therapy is being given. Sofia’s Disease Manager has a standing order for an A1C test to be performed whenever other blood work is done on Sofia. Those results are returned to Sofia’s PCP and her Disease Manager. This ensures that Sofia’s diabetes is always being monitored. Her Care Team members watching this condition can get engaged if test results indicate the need. The EHR systems used by Sofia’s Payer Disease Manage and her PCP include decision support rules that alert care team members if lab result values for Sofia’s A1C test come back higher than expected.

 

20170204 Care Plan-Payer*

20170210 Genetic Testing Results*

20170213 Genetic Testing Letter*

 

 

 

 

20170306 Progress Note*

 

 

 

 

20

Feb 27-August 3

 

Sofia’s Medical Oncologist continues ordering lab tests and imaging exams to track Sofia’s progress following the chemo therapy.

 

20170515 Progress Note*

20170803 Progress Note*

21

March 15 th

Results for Sofia’s A1C test trigger a call from her PCP. He orders a medication change for her diabetes.

20170315 Progress Note*

22

July 15th

Sofia has a follow-up visit to her PCP to discuss how her diabetes control is going after making the medication change. They discuss some of the additional things Sofia should be doing to manage her diabetes and address other preventive health tests.  Sofia explains how hard it is to manage all her current appointments. The PCP performs the foot exam and performs the nephrology screening based upon recent BUNN scores from her lab work. They agree she will focus on these getting the additional visits/screenings after she gets finished recuperating from the upcoming surgery.

20170715 Progress Note*

23

August 10th

Sofia’s care team meets to discuss the results of her post-chemo evaluation and the plans for her surgery are set. Sofia’s full records are shared with the surgeon in Philadelphia.

 

20170810 Progress Note*

20170810 CCD*

24

August 17 th,

 

Sofia goes to Philadelphia for her pre-surgery consult. Lumpectomy is confirmed for the next day. Sofia completes all her pre-op requirements at the hospital.

 

20170815 ADVANCE CARE PLAN

20170817 BREAST SURGON PRE SURGERY

20170817 PREOPERATIVE INSTRUCTIONS

20170817 PREADMISSION TESTING

 

25

August 18 th

Sofia’s lumpectomy is performed. Samuel stays at his sister-in-law’s following the surgery and then return to Pittsburgh following her post-op visit with the surgeon. The surgeon provides Sofia’s care team with updated information about her surgery and her post-op progress.

 

20170818 Operative Note*

20170819 PROCEDURE NOTE

 

 

26

August 18th

Sofia is discharged. They stay with her sister for two days of rest, before returning to Pittsburgh.

Message*

20170818 Discharge Summary*

20170819 DISCHAGE SUMMARY

27

August 19 th

The tumor board reviews the post-op information and provides the Medical Oncologist with information that helps to determine the follow-up radiation treatment options.

 

20170819 Progress Note*

20170819 PATHOLOGY REPORT

 

28

August 25 th

Sofia and Samuel meet with the Medical Oncologist to discuss the recommendations. He recommends radiation treatment and Oncotype DX testing to inform the treatment plan. (The Medical Oncologist was able to pre-authorize the Onco DX testing prior to the consultation with Sofia.) Sofia decides to go forward with the testing and the radiation therapy. The Medical Oncologist refers her to a Radiation Oncologist.

 

20170825 Progress Note-MedOnc*

20170825 Care Plan-Payer*

20170825 Referral Note*

20170825 PROGRESS NOTE

29

August 26th

Sofia and Samuel meet with the Radiation Oncologist who explains the treatment plan for Sofia.

 

20170826 Care Plan-RadOnc*

20170826 Consultation Note*

30

Sept 17th

Sofia begins radiation treatments 3 weeks after her surgery. For 6 weeks, Sofia receives radiation treatments, daily on Monday through Friday, under the care of the Radiation Oncologist.

 

20170930 Progress Note*

20171020 Discharge Summary*

31

October 1

Samuel’s ACO offers a smoking cessation program that covers anyone in the family who smokes.  Sofia decides to do the class with Samuel, so they can support each other to quit smoking once and for all.

 

32

Oct 15 - Nov 30

Sofia and Samuel complete a 6-week smoking cessation program and vow to each other to remain non-smokers together for the rest of their lives.

 

The EHR systems used by Sofia’s Payer Disease Manage and her PCP include decision support rules that produce periodic reports for members who are not compliant with quality measures used to establish best practice care for individuals based on relevant populations for each person.

 

 

33

Oct 23rd

After completing radiation therapy, Sofia meets with her Medical Oncologist to review next steps.

 

20171023 CarePlan-MedOnc*

34

Oct 24th

Sofia’s care is transitioned back to her PCP.  The Medical Oncologist sends a cancer survivorship plan to Sofia’s PCP to supply care guidelines for Sofia’s care following her cancer treatments.

 

20171024 Cancer Survivorship Plan*

35

Oct 30th

Sofia sees her PCP for her annual exam.

 

20171030 H&P Document*

36

November 10th and follow-on appointments

Sofia continues to have follow-up visits with the Oncologist. They are scheduled once every 3 months during the first 2 years, then once every 6 months for two years. In mid-December Sofia has an eye exam and has her long-overdue colonoscopy. Sofia’s care team at the PCMH track her progress on these interventions considered best practice for health outcomes so that Sofia is more engaged in managing her health going forward.

 

20171210 Progress Note*

 

20171221 Progress Note*

37

Annual exam each Fall with PCP. Touch-point calls from Disease Manager as triggered by changes in Sofia’s care (i.e. visits to the ER or re-occurrence of cancer)

 

Sofia’s PCP and Oncologist continue to share information about the on-going care that Sofia receives and her health status.

 

The Payer Disease Manager continues monitoring Sofia’s clinical health information to help prevent and manage complications from her diabetes, hypertension and prior cancer treatments.

 

 

20171231 Care Plan-PCP*

20171231 CCD*

 

 

 

20171231 Care Plan-Payer*

 

[Note:  At time of ballot, not all synthetic clinical data files have been populated.  It is anticipated the clinical data files associated with this story board will improve and mature as the story board is utilized.]

 

Timeline View for Sofia

An open source application developed at the Journalism School of Northwestern University was used to create a timeline of Sofia’s life. The application is call the knight lab Timeline JS.  The application is available on the web at: http://timeline.knightlab.com/

Access the timeline directly through a web browser using the ling below. ( If you're embedding on Medium.com or other oembed-aware services, just paste this link on a line by itself where you want your timeline to appear.)

https://cdn.knightlab.com/libs/timeline3/latest/embed/index.html?source=1BeSL7FZ7a_hsvsz_XF3s4GXCWDFtf_SGssBhyy4bzKk&font=Default&lang=en&initial_zoom=1&height=650

To insert the timeline into a website, copy this embed code and paste it on your site where you want your timeline to appear (just like a YouTube video).

<iframe src='https://cdn.knightlab.com/libs/timeline3/latest/embed/index.html?source=1BeSL7FZ7a_hsvsz_XF3s4GXCWDFtf_SGssBhyy4bzKk&font=Default&lang=en&initial_zoom=1&height=650' width='100%' height='650' webkitallowfullscreen mozallowfullscreen allowfullscreen frameborder='0'>

</iframe>

Detailed Narrative and Timeline - Samuel

Event

Date

Details

1

January 26 th

Samuel flew to Michigan on January 20 th to help his Mother move into an assisted living center. While moving the couch, he falls and breaks his wrist. He calls 911 and is taken to the Emergency Department (ED) at a nearby hospital.

 

2

Note: Can Samuel’s admission to the ED trigger communication back to his PCP’s ACO in Pittsburgh?

In the ED he complains of experiencing pain at the base of his right thumb and lateral wrist. Physical examine finds tenderness in the anatomic snuffbox and selling indicative of scaphoid fracture (Colle’s fracture).  An x-Ray of the wrist is ordered. The radiograph rules out both distal radius fracture and displaced scaphoid fracture, so surgery is not needed. Samuel’s wrist is placed in a thumb spica cast.  He is asked to follow-up with a local orthopedic specialist to have another x-Ray in 7-10 days. 

 

Samuel asks the ER Team to contact the Care Manager at his PCP’s office so that they can arrange for his follow-on care back in Pittsburgh.

 

 

3

 

ER doctor explains that Samuel needs to take it easy and rest his arm for the next few weeks. Samuel is concerned about making is flight back to Pittsburgh the following day.  He will need to hire a moving company to finish his mother’s move and then needs to get back to support his wife who has just been diagnosed with breast cancer.

 

4

 

The ER docs contacts the Care Manager at Samuel’s PCP practice.  She helps provide documentation that Samuel can use to re-arrange his flights and she explains the process for getting assistance during his travel, so he won’t stress his fractured wrist. She makes an appointment for Samuel to see an Orthopedic Specialist in their ACO network for the week after he gets back to Pittsburg, so he has time to deal with his wife’s needs first. She makes sure the care team in Michigan knows where to forward all of Samuel’s care information from the ED encounter.

 

5

January 31

Samuel goes to the Medical Oncologist consult with Sofia. Sofia drives so Samuel can rest his wrist.

 

6

Feb 2 nd

Sofia drives Samuel to see the Orthopedic doctor in Pittsburgh. They take another radiograph in the office and confirm there is only a very minor scaphoid fracture.

 

7

Feb 6 - 24

The couple receives support services while Sofia is undergoing heavy chemo and Samuel is not able to drive or help much around the house. The home helper drive Sofia and Samuel to medical appointments, helps with grocery shopping, meal preparation and light housework.

 

8

March 2, June 1st

The Orthopedic doctor sees Samuel every 4 weeks for 2 months to confirm his progress while his wrist was healing. When Samuel’s wrist was sufficiently healed, the Orthopedic doctor refers him to a Physical Therapist (PT) for 4 months of physical therapy.

 

9

April 3 – May 29

The PT sees Samuel. She does a History & Physical and establishes a care plan. She creates a consultation note to return information back to Samuel’s PCP. Samuel makes good progress and meets his physical therapy goals. The PT discharges him at the end of May. The PT shares Samuel’s progress notes and his discharge information with his PCP and Orthopedic Specialist.

 

10

June 1

Samuel’s Orthopedic Specialist shares outcome information with Samuel’s PCP and the ED in Michigan regarding Samuel’s wrist fracture treatment.

 

11

July 15

After going through this experience with his wife, Samuel begins to feel differently about the value of screening and other preventive care options.  He agrees to have a colonoscopy done and signs up for a smoking cessation program offered though his ACO. The smoking cessation program covers anyone in the family who smokes.  Sofia decides to do the class with Samuel, so they can support each other to quit smoking once and for all.

 

12

Aug 15

Samuel has the colonoscopy and results are negative for colorectal cancer. the Proctologist send him his results and instructs him to undergo screening again in ten years.

 

13

October 1

Samuel’s ACO offers a smoking cessation program that covers anyone in the family who smokes.  Samuel decides to do the class. Sofia decides to take the course too, so they can support each other to quit smoking once and for all.

14

Oct 15 - Nov 30th

Samuel and Sofia complete a smoking cessation program and vow to each other to remain non-smokers together for the rest of their lives.

 

The EHR system used by Samuel’s ACO includes decision support rules that produce periodic reports for members who are not compliant with quality measures used to establish best practice care for individuals based on relevant populations for each person.

[Note:  At time of ballot, no synthetic clinical data files have been populated for Samuel’s story.  It is anticipated the clinical data files associated with this story board will improve and mature as the story board is utilized.]

Synthetic Data

Creation of synthetic data was developed as timing and resources permitted.  Entity and system information have been supplied below. A set of synthetic data files were created to provide clinical content that can be used to augment the story.  For Sofia, some synthetic data files were crafted by hand as CCDA Documents.  Additionally, PDF documents were developed to provide realistic clinical data to accompany her scenario.  Similar clinical data was not available for Samuel’s story. However, Care Team and System actor information has been provided for Samuel’s scenario.

The synthetic data files are contained in a zip file with the ballot package.  Ballot feedback is requested regarding feasible means to develop and create realistic clinical data to accompany cross paradigm story boards.

The synthetic data can be used to test or examine technical capabilities and standards designed to support interoperability.   It is anticipated the clinical data files associated with this story board will improve and mature as the story board is utilized.

Generate rich, realistic synthetic data is very difficult.  If it is determined that including synthetic data with story board artifacts is useful, additional capabilities will need to be developed to make synthetic data generation more feasible.

 

Care Team Actors - Sofia

Care Team Member

Details

Sofia Mateo

 

Care Team Member Function:

Patient

Name: Sofia Maria Mateo

Address 1: 123 Neighborhood Drive

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Cell: 412 123 1234

Home: 412 987 6543

Work: 412 555 1234

Common e-mail: SofiaMMateoPA@gmail.com

Assigning Authority: Direct Trust

Direct Address: Sofia.Mateo@direct.MyPHD.us

Birthdate: February 1 st (turns 57 in the year of story)

Gender: Female

Marital status: Married

Religion: Catholic

Race: White

Ethnicity: Hispanic or Latino

Employer: ABC, Inc.

Health Insurance Plan info:

Health Insurance Plan: Cigna PPO(62308)/MagellanRx(017449)
Details: member=192837465, Group=S63
RxDetails: member=192837465, BIN=017449, PCN=6792000, Group=PRXCBE

 

Advance Directives:

None available initially, but then after receiving the Cancer Diagnosis, but Sofia and Samuel create their Advance Directives using MyDirectives.com.

Health Plan Disease Manager

 

Care Team Member Function:

Disease Manager

NOTE: HIPAA Privacy Role is treatment and operations, based on employer, plan and status of member enrollment in disease management programs.  

Name: Nancy Nurse, RN

NPI:223456789

Licensure: 163W00000X Registered Nurse

Address 1: 500 East Main Street

Address 2:

City: Louisville

State: KY

Zip: 40202

Telecom: 800 486 2020

Assigning Authority: Direct Trust

Direct Address: Nurse.Nancy.RN@direct.Cigna.com

Organization Name: Cigna

Org Address 1: 500 East Main Street

Org Address 2:

Org City: Louisville

Org State: KY

Org Zip:40202

Org Telecom: 800 486 2000

Org Assigning Authority: DirectTrust

Org Direct Address: Cigna-DM@direct.cigna.com

 

Health Plan Case Manager

 

Care Team Member Function:

Case Manager

 

NOTE: HIP AA Privacy Role is operations, based on employer, the plan ’s approach to care   management programs and population health .

Name: Casey Manager, RN

NPI: 1123456789

Licensure: 163WA2000X Nurse Administrator

Address 1: 500 East Main Street

Address 2:

City: Louisville

State: KY

Zip: 40202

Telecom: 800 486 2020

Assigning Authority: Direct Trust

Direct Address: Casey.Manager.RN@direct.Cigna.com

Organization Name: Payer One

Org Address 1: 500 East Main Street

Org Address 2:

Org City: Louisville

Org State: KY

Org Zip:40202

Org Telecom: 800 486 2000

Org Assigning Authority: Direct Trust

Org Direct Address: Cigna-CM@direct.Cigna.com

 

Attributed PCP starting October 2014

 

Care Team Member Function:

Primary Care Provider

Name: John Smith, MD

NPI: 234599999

Licensure: 207R00000X Internal Medicine

Address 1: 40 Healthcare Ave.

Address 2: Suite 100

City: Pittsburgh

State: PA

Zip: 15235

Work: 412 222 4321

Assigning Authority: DirectTrust

Direct Address: Dr.Smith@direct.JohnSmithMd.com

Organization Name: John Smith, MD, LLC

Org Address 1: 40 Healthcare Ave.

Org Address 2: Suite 100

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom:412 555 5555

Assigning Authority: DirectTrust

Direct Address: Office@direct.JohnSmithMd.com

 

Attributed PCP starting October 2016

 

Care Team Member Function:

Primary Care Provider

Name: Patricia Primary, MD

NPI: 234567891

Licensure: 207R00000X Internal Medicine

Address 1: 123 Healthcare Ave.

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Work: 412 222 1234

Assigning Authority:

Direct Address:

Organization Name: Primary Care of Pittsburgh

Org Address 1: 123 Healthcare Ave.

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom:412 222 5555

Org Assigning Authority: Direct Trust

Org Direct Address: Office@direct.PCP.com

 

Nutritionist

 

Care Team Member Function:

Nutritionist

Name: Eaton Better

NPI: 345675432

Licensure: 132700000X Dietary Manager

Address 1: 123 Healthcare Ave.

Address 2: Suite 202

City: Pittsburgh

State: PA

Zip: 15235

Work: 412 222 4567

Assigning Authority: DirectTrust

Direct Address: Eaton.Better@direct.PCP.com

Organization Name: Primary Care of Pittsburgh

Org Address 1: 123 Healthcare Ave.

Org Address 2: Suite 202

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom:412 222 5555

Org Assigning Authority: Direct Trust

Org Direct Address: NAD@direct.PCP.com

 

GYN

 

Care Team Member Function:

Gynocologist

Name: Robert Bewell, MD

NPI: 345678912

Licensure: 207V00000X Obstetrics & Gynecology

Address 1: 404 Main Street

Address 2:

City: Pittsburgh

State:

Zip: 15235

Work: 412 777 2345

Assigning Authority: Direct Trust

Direct Address: Dr.Bewell@direct.WGC.com

Organization Name:  Woman’s Gynecologic Center

Org Address 1: 408 Main Street

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 777 5000

Org Assigning Authority: Direct Trust

Org Direct Address: WGC@direct.WGC.com

 

Radiologist/Imaging Center

 

 

Name: William Reader, MD

NPI: 456789123

Licensure: 2085U0001X Diagnostic Ultrasound

Address 1:

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Telecom: 412 222 5678

Assigning Authority: DirectTrust

Direct Address: DrReader@direct.PMC.com

Organization Name: PMC Imaging Center

Org Address 1: 500 Main Street

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 555 5000

Org Assigning Authority: Direct Trust

Org Direct Address: ImagingCenter@direct.PMC.com

 

Medical Oncologist

 

Care Team Member Function:

Medical Oncologist

Name: Kendal B. Better, MD

NPI: 567891234

Licensure: 207RX0202X Medical Oncology

Address 1: 333 Treatment Way

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Telecom: 412 777 2001

Assigning Authority: Direct Trust

Direct Address: DrKenBBetter@direct.PCC.com

Organization Name: Pittsburgh Cancer Center

Org Address 1: 333 Treatment Way

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 777 2000

Org Assigning Authority: Direct Trust

Org Direct Address:  Admin@direct.PCC.com

 

Nurse Oncologist

 

Care Team Member Function:

Nurse Oncologist

Name: Caryn Forhugh, MD

NPI: 678912345

Licensure: 163WX0200X Nurse Oncology

Address 1: 333 Treatment Way

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Telecom: 412 777 2001

Assigning Authority: Direct Trust

Direct Address: Caryn.Forhugh@direct.PCC.com

Organization Name: Pittsburgh Cancer Center

Org Address 1: 333 Treatment Way

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 777 2000

Org Assigning Authority: Direct Trust

Org Direct Address:  Admin@direct.PCC.com

 

Pathologist

Pat Hallowgist

NPI: 789129999

Licensure: 207ZP0102X Anatomic Pathology  & Clinical Pathology

Address 1:  1001 Treatment Way

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Telecom: 412 888 8001

Assigning Authority: Direct Trust

Direct Address: DrHallowgist@direct.PMC.com

Organization Name: Pittsburgh Medical Center

Org Address 1: 1001 Treatment Way

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 888 8000

Org Assigning Authority: Direct Trust

Org Direct Address: Pathology@direct.PMC.com

 

General Surgeon

 

 

Care Team Member Function:

Surgeon

Name: S. Teddy Hand, MD

NPI: 789123456

Licensure: 208600000X Surgery

Address 1:  1001 Treatment Way

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Telecom: 412 888 8001

Assigning Authority: Direct Trust

Direct Address: DrSTeddyHand@direct.PCC.com

Organization Name: Pittsburgh Medical Center

Org Address 1: 1001 Treatment Way

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 888 8000

Org Assigning Authority: Direct Trust

Org Direct Address: SurgeryDept@direct.PMC.com

 

Tumor Board #1

Organization Name: Pittsburgh Medical Center Tumor Board

Org Address 1: 1001 Treatment Way

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 888 8000

Org Assigning Authority: Direct Trust

Org Direct Address: TumorBoard@direct.PCC.com

 

Surgical Oncologist

 

Care Team Member Function:

Surgeon

Name: Sue Ture, MD

NPI: 891234123

Licensure: 2086X0206X Surgical Oncology

Address 1: 205 Careway Boulevard

Address 2:

City: Philadelphia

State: PA

Zip: 19103

Telecom: 215 777 1234

Assigning Authority: DirectTrust

Direct Address: Dr.Ture@direct.surgicalassoc.com

Organization Name: Surgical Associates

Org Address 1: 205 Careway Boulevard

Org Address 2:

Org City: Philadelphia

Org State: PA

Org Zip: 19103

Org Telecom: 215 777 1000

Org Assigning Authority: Direct Trust

Org Direct Address: Office@direct.surgicalassoc.com

 

Tumor Board #2

Organization Name: Philadelphia Cancer Treatment Center

Org Address 1:  123 Careway Blvd.

Org Address 2:

Org City: Philadelphia

Org State: PA

Org Zip: 19103

Org Telecom: 215 777 1234

Org Assigning Authority: DirectTrust

Org Direct Address:TumorBoard@direct.PCTC.com

 

Companion Care Co.

 

Care Team Member Function:

Community Based Home Services

Organization Name: Home Care Specialists

Org Address 1: 123 Jefferson Street

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 888 123 4444

Org Assigning Authority: Direct Trust

Org Direct Address: Info@direct.homecareInc.com

 

Companion for light house work (Home Health Aide)

 

Care Team Member Function:

Home Health Aide

Name: Mary Helper

Organization Name: Home Care Specialists

Org Address 1: 123 Jefferson Street

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 888 123 4444

Org Assigning Authority: Direct Trust

Org Direct Address: Mary.Helper@direct.homecareinc.com

 

Radiation Oncologist

Name: Robert Lazer, MD

NPI: 912345678

Licensure: 2085R0001X Radiation Oncology

Address 1: 555 Healthy Way

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Telecom: 412 999 1234

Assigning Authority: Direct Trust

Direct Address: Dr.Lazer@direct.PittsburghCI.com

Organization Name: Pittsburgh Cancer Institute

Org Address 1: 555 Healthy Way

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 999 1000

Org Assigning Authority: Direct Trust

Org Direct Address: Office.Mgr@direct.PittsburghCI.com

 

 

System Actors – Sofia

Western PA HIE

Organization Name: Western PA HIE

Org Address 1: 100 Interoperability Way

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 333 9876

 

Assumptions about the version supported for various standards can be applied to explore information exchange challenges that may arise for this storyboard.

Eastern PA HIE

Organization Name: Eastern PA HIE

Org Address 1: 100 Exchange Street

Org Address 2:

Org City: Philadelphia

Org State: PA

Org Zip: 19103

Org Telecom: 215 888 1000

 

Assumptions about the version supported for various standards can be applied to explore information exchange challenges that may arise for this storyboard.

HISP systems

Health Information Service Providers are a different kind of system actor from an HIE. They exist to securely transport and deliver health information within the health ecosystem. While Health Information Exchange systems may also provide this transport function, their connections tend to be established via persistent data communication channels developed between organizations that have agreed to share data. They may offer a view and download option, but non-persistent data communication channels are not a part of the HIE design. The functionality of non-persistent data communication is attributed to a HISP system.  Some HIEs are beginning to also support HISP functionality. For the purpose of this storyboard artifact, HIE and HISP functionality are considered as being delivered by distinct system actors.

EMR systems, other patient management and member management systems and personal health record systems

Each organization running a system to manage patient/member/personal health information may produce any of the following types of CDA documents:  C32, C-CDA R1.1 documents, or C-CDA R2.1 Documents. Some systems may have some FHIR API capabilities implemented in FHIR DSTU 2 and other may have implemented FHIR STU 3, in which case, FHIR resources, profiles, and operations may be utilized to share information among care team members from distinct legal entities.

 

Note, the present care paradigm makes it difficult to express the patient and family members involved in care as part of the set of care team members. While other care team members easily can be described as belonging to different legal entities, there is no “organization” that the patient and the family members belong to. Personal, familial and legal relationships to the patient may organize certain care team members in support of the patient, they don’t belong to an “organization” in the same sense that the employed doctors, nurses, and other care team members do. This structural difference causes a “misalignment” within the natural situation we are attempting to model and describe.   

 

Assumptions about the version supported for various standards can be applied to explore information exchange challenges that may arise for this storyboard.

 

Care Team Actors – Samuel

Care Team Member

Details

Samuel Mateo

Name: Samuel Ray Mateo

Address 1: 123 Neighborhood Drive

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Cell: 412 321 4321

Home: 412 987 6543

Work: 412 444 1234

Common e-mail: SamuelRMateoPA@gmail.com

Assigning Authority: Direct Trust

Direct Address: Samuel.Mateo@direct.MyPHD.us

Birthdate: January 2 nd (turns 59 in the year of story)

Gender: Male

Marital status: Married

Religion: Catholic

Race: White

Ethnicity: Hispanic or Latino

Employer: XYZ, Co.

Payer: Payer Two, First Avenue Place, 100 First Avenue, Pittsburgh, PA 15222, 412 544-3000

Health Insurance Plan info:  [Need to know what details go here.]

 

PCP

Name: Patrick Provider, MD

NPI: 111111111

Licensure: 207Q00000X Family Medicine

Address 1: 567 Healthy Way

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Work: 412 333 4321

Assigning Authority:

Direct Address:

Organization Name: Community Primary Care

Org Address 1: 567 Healthy Way

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom:412 333 1212

Org Assigning Authority: Direct Trust

Org Direct Address: CommunityPrimaryCare@direct.CPC.com

 

Care Manager with PCP practice

Name: Nancy Nursemanager, RN

NPI: 2121212121

Licensure: 163WC0400X Case Management

Address 1: 567 Healthy Way

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Work: 412 333 4321

Assigning Authority:

Direct Address:

Organization Name: Community Primary Care

Org Address 1: 567 Healthy Way

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom:412 333 1212

Org Assigning Authority: Direct Trust

Org Direct Address: CommunityPrimaryCare@direct.CPC.com

 

ED Attending Physician

Name: Eric Provider, MD

NPI: 234234234

Licensure: 207R00000X Internal Medicine

Address 1: 567 Healthy Way

Address 2:

City: Lansing

State: MI

Zip: 48864

Work: 517 444 1234

Assigning Authority:

Direct Address:

Organization Name: Lansing Community Hospital

Org Address 1: 111 Care Street

Org Address 2:

Org City: Lansing

Org State: MI

Org Zip: 48864

Org Telecom: 517 444 1233

Org Assigning Authority: Direct Trust

Org Direct Address: ER@direct.LCH.com

 

Imaging Technician

Name: Thomas Imager

NPI: 567567567

Licensure:

Address 1: 567 Healthy Way

Address 2:

City: Lansing

State: MI

Zip: 48864

Work: 517 444 1234

Assigning Authority:

Direct Address:

Organization Name: Lansing Community Hospital

Org Address 1: 111 Care Street

Org Address 2:

Org City: Lansing

Org State: MI

Org Zip: 48864

Org Telecom: 517 444 1233

Org Assigning Authority: Direct Trust

Org Direct Address: ER@direct.LCH.com

 

Hospital Radiologist

Name: Raymond Reader, MD

NPI:456456456

Licensure: 2085R0202X Diagnostic Radiology

Address 1: 567 Healthy Way

Address 2:

City: Lansing

State: MI

Zip: 48864

Work: 517 444 1234

Assigning Authority:

Direct Address:

Organization Name: Lansing Community Hospital

Org Address 1: 111 Care Street

Org Address 2:

Org City: Lansing

Org State: MI

Org Zip: 48864

Org Telecom: 517 444 1233

Org Assigning Authority: Direct Trust

Org Direct Address: ER@direct.LCH.com

 

Orthopedic Specialist

Name: Oscar Bones, MD

NPI:789789789

Licensure: 207XX0004X Foot and Ankle Surgery

Address 1: 100 Well Street

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Work: 412 214 4321

Assigning Authority:

Direct Address:

Organization Name: Ortho Specialists

Org Address 1: 100 Well Street

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom:412 214 1000

Org Assigning Authority: Direct Trust

Org Direct Address: DrBones@direct.OrthoSpecialists.com

 

Physical Therapist

Name: Jan Mobility, PhD

NPI: 123412341

Licensure:  225100000X Physical Therapist

Address 1: 100 Bend More Street

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Work: 412 333 9876

Assigning Authority: Direct Trust

Direct Address: Jan@direct.FirstPhysical.com

Organization Name: First Physical

Org Address 1: 100 Bend More Street

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 333 9876

Org Assigning Authority: Direct Trust

Org Direct Address: DrJan@direct.FirstPhysical.com

 

 

Proctologist

Name: Collin Scoper, MD

NPI: 987654321

Licensure:  Colon and Rectal Surgeon

Address 1: 100 Well Street

Address 2:

City: Pittsburgh

State: PA

Zip: 15235

Work: 412 214 9876

Assigning Authority:

Direct Address:

Organization Name: Shorline Proctology Care

Org Address 1: 100 Well Street

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom:412 214 3030

Org Assigning Authority: Direct Trust

Org Direct Address: DrScoper@direct.ShorelineCare.com

 

 

System Actors – Samuel

Western PA HIE

Organization Name: Western PA HIE

Org Address 1: 100 Interoperability Way

Org Address 2:

Org City: Pittsburgh

Org State: PA

Org Zip: 15235

Org Telecom: 412 333 9876

 

Assumptions about the version supported for various standards can be applied to explore information exchange challenges that may arise for this storyboard.

MI HIE

Organization Name: Michigan HIE

Org Address 1: 1001 Information Highway

Org Address 2:

Org City: Ann Arbor

Org State: MI

Org Zip: 48103

Org Telecom: 734 999 1000

 

Assumptions about the version supported for various standards can be applied to explore information exchange challenges that may arise for this storyboard.

HISP systems

Health Information Service Providers are a different kind of system actor. They exist to securely transport and deliver health information within the health ecosystem. While Health Information Exchange systems may also provide this transport function, their connections tend to be established via persistent data communication channels developed between organizations that have agreed to share data. They may offer a view and download option, but non-persistent data communication channels are not a part of the HIE design. The functionality of non-persistent data communication is attributed to a HISP system.  Some HIEs are beginning to also support HISP functionality. For the purpose of this storyboard artifact, HIE and HISP functionality are considered as being delivered by distinct system actors.

EMR systems, other patient management and member management systems and personal health record systems

Each organization running a system to manage patient/member/personal health information may produce any of the following types of CDA documents:  C32, C-CDA R1.1 documents, or C-CDA R2.1 Documents. Some systems may have some FHIR API capabilities implemented in FHIR DSTU 2 and other may have implemented FHIR STU 3, in which case, FHIR resources, profiles, and operations may be utilized to share information among care team members from distinct legal entities.

 

Note, the present care paradigm makes it difficult to express the patient and family members involved in care as part of the set of care team members. While other care team members easily can be described as belonging to different legal entities, there is no “organization” that the patient and the family members belong to. Personal, familial and legal relationships to the patient may organize certain care team members in support of the patient, they don’t belong to an “organization” in the same sense that the employed doctors, nurses, and other care team members do. This structural difference causes a “misalignment” within the natural situation we are attempting to model and describe.   

 

Assumptions about the version supported for various standards can be applied to explore information exchange challenges that may arise for this storyboard.

 

 


[KC1] Overall comment – lots of redundancies that may be useful for standards developers but frustrating for business users.  Suggest that you have 2 versions – one that follows standards Use Case development and one that rolls up the scenarios for Biz Users.  Also – redundancy is the mother of inconsistency – so may want to have source of truth and then expand to redundancy needed for developers.

[JL2] Not viable to have two versions.  The audience is HL7 participants, not laymen biz owners. 

[KC3] Should have an overarching timeline – combining both patients so that readers can reorient if lost in the multiple renditions of same stories.

[KC4] does she use VDT or Right of Access? Difference in privacy policies. Later is not governed by HIPAA but she’s able to be much more specific about what she wants access to. Under VDT she’s limited to CCDEs specified by MU.

[JL5] Clarified as VDT

[KC6] Later in story she’s driving husband – so need to reconcile – maybe here say she doesn’t like to drive? LENEL, agree

[KC7] Since there’s no further follow up on this event – is it useful or noise? LENEL – it is part of data flow to the Care Plan.

 

[KC8] Is this the correct procedure term? Probably. Need to add to dictionary and perhaps a link to definition because it comes up as an error. LENEL – it is correct, as an advance procedure, link added.

[KC9] Introducing the Case Manager w/o context – is this a case manager under HIPAA Treatment or Operations?  There’s a world of privacy policy differences between the 2 actor roles.  This should be clarified at the beginning – Actors, Legitimate relationships under HIPAA and other laws. 

[KC10] is this meant to be one term? 

[KC11] Is Tumor Board review, while actually part of real life work flow, of any significance to the workflow being captured for standards development.  I didn’t see the hook. Suggest reviewing pertinence.

[KC12] This is an opportunity for exploring privacy implications. E thical dilemma for Sofia and family is whether she’ll agree to have insure pay for genetic test or invoke HIPAA Self-Pay consent, which providers are mandated to accept. I.e., she may decide that while she wants genetic information to help personalize her chemo, she doesn’t want the genetic analysis to implicate all of her ascendant/descendent health profiles.  Under HIPAA, the provider is required to agree to her restrictions on collection/use/disclosure of the order and results of genetic testing.  So provider’s EHR needs capability to label with HIPAA Out of Pocket Restrictions, which would manually or automatically bar disclosure of this information to payers listed in her HIPAA consent – e.g., she might permit disclosure to her insurer and restrict to her husband’s insurer, which is secondary.  HL7 security labels can be used on HL7 v2, CDA, and FHIR.  Should be indicated in provider’s practice management software file for this charge.  Would be timely/interesting to see how this security label would be persisted through the workflow to the X12 claims transaction. If there were one “proof point” of importance in the AWG exercise of adding privacy/security enforcement of privacy – it would be demonstrating that providers whether working in ACOs or other arrangements – are able to support patient choice.  This use case is a salient example.