Evaluation and Outcomes Lisa Nelson, MS, MBA Have we mixed things - - PowerPoint PPT Presentation

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Evaluation and Outcomes Lisa Nelson, MS, MBA Have we mixed things - - PowerPoint PPT Presentation

Jul 03, 2023 271 likes •371 views

Health Status Evaluation and Outcomes Lisa Nelson, MS, MBA Have we mixed things up? Can we sort them out better now to avoid making ourselves nuts later? Agenda Why talk about this here? The basic model for care plan information

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SLIDE 1

Health Status Evaluation and Outcomes

Lisa Nelson, MS, MBA

Have we mixed things up? Can we sort them

  • ut better now

to avoid making

  • urselves nuts

later?

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SLIDE 2

Agenda

  • Why talk about this here?
  • The basic model for care plan information
  • Health Status Evaluation and Outcomes
  • Health Concerns
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SLIDE 3

Why Are Care Plans So Important?

Triple Aim

Positive Health Outcomes for the Patient

Thomas Feeley, M.D., “Transforming Medicine Through Value-Based Healthcare”.

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SLIDE 4

Plenty of Experimentation and Exploration!

Care Plans

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SLIDE 5

12 Care Plan Standards Initiatives

5 Initiative Technology (Vendor) Standard HL7/BCBSA: Care Plan Proof of Concept (2015)
  • ZeOmega
  • Edifecs
  • GSI Health
  • Healthwise
  • C-CDA 2.1 Care Plan Document
Template
  • Care Plan DAM
Greater New York Hospital Association: NY DSRIP Implementation. Phase 1 Pilots (Jan 16 to Nov 16); Phase 2 Pilots (Jan 2017+)
  • GSI Health
  • Crimson/ Epic
  • Altruista
  • Intersystems (supports HealthIX HIE)
  • Allscripts
  • Builds off BCBSA Proof of
Concept Project
  • C-CDA 2.1 Care Plan Document
Template VA Care Coordination for Improved Outcomes Challenge
  • Systems Made Simple (Lockheed)
  • FHIR Care Plan Resource
  • Care Plan DAM
NIH NIDDK Chronic Kidney Disease (CKD) Care Plan Project
  • TBD
  • C-CDA 2.1 Care Plan Document
Template Apple Care Plan
  • Apple HealthKit IOS10
  • C-CDA CCD
Early Hearing Detection and Intervention (EHDI) Hearing Care Plan Pilot: Oregon Health Authority (June 2015)
  • Epic
  • IHE QRPH EHDI Hearing Care
Plan of Care
  • IHE PCD-01
Utah Health Department Newborn hearing screening care coordinaiton (ONC HIE Grantee): Utah Department of Health, Utah Health Information Network (UHIN) and Intermountain Healthcare (Sept 2015 to Sept 2016)
  • C-CDA 2.1
  • DIRECT
  • IHE QRPH EHDI Hearing Care Of
Plan
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SLIDE 6

12 Care Plan Standards Initiatives – (continued)

6 Initiative Technology (Vendor) Standard NCPDP/HL7 Pharmacist eCare Plan Pilots
  • Community Care of NC (CMMI Grantee)
  • Great Plains Area (ND, SD, IA, NE) of IHS
  • QSI Data Systems
  • PioneerRX Pharmacy Software
  • Rx30
  • Computer RX
  • VIP Pharmacy Systems
  • Creative Pharmacist
  • HL7 ePharmacy eCare Plan IG (based on
C-CDA 2.1 and FHIR Care Plan Resource) Connecticut Department of Social Services (DSS)/ University of Connecticut School of Nursing (CMS TEFT Demonstration)
  • CT DSS web-based CFC case
management system
  • C-CDA 2.1 Care Plan Document Template
  • eLTSS dataset (in development)
Comprehensive Primary Care Initiative (CPC+) Track 2 CMMI Grantee (target Q42018)
  • TBD
  • C-CDA 2.1 Care Plan Document Template
Veterans Administration (VA) Salt Lake City Health Care System: Shared Care Planning
  • TBD
  • FHIR Risk Assessment Resource
  • FHIR Patient Resource
  • FHIR Goal Resource
  • FHIR Clinical Resources
  • FHIR Workflow Resource
Argonaut Project
  • Cerner
  • Epic
  • MEDITECH
  • McKesson
  • Surescripts
  • Argonaut Implementation Guide (based
  • n DAF FHIR Implementation Guide)
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SLIDE 7

What Is Care Plan Information and How Does It Work Together?

EVALUATION/OUTCOMES Progress Toward Goal Observation (mood EVN) Observation (mood EVN) HAS SUPPORT Health Concern (code = CONCERN or RISK) (mood EVN) HAS COMPONENT REFERS TO Intervention (mood: INT/RQO/ etc,) (mood: EVN) REFERS TO Goal (mood GOL) HAS COMPONENT REFERS TO HAS REASON HAS REASON EVALUATES Supports Outcome Observation (mood EVN)
  • Health concern/problem (Need/Issue)
  • Health goal (Goal/Objective)
  • Intervention/activity (Action)
  • Evaluation/outcomes (Progress)

Care Plan Standards define ‘containers’ to capture and relate care plan information (Structure & Semantics)

Evaluations/Outcomes

HL7 Care Plan Domain Analysis Model (2016) Interoperability:

  • Syntax
  • Structure
  • Semantics
  • Process
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SLIDE 8

The ask:

Should we move the Health Status entry template into the Health Status Evaluation and Outcome section?

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