Multiple Chronic Conditions MCC electronic Care Plan Project

Multiple Chronic Conditions (MCC) electronic Care Plan Project IG Development Gay Dolin MSN RN

Reusing and Constraining Process Constrained Profile Example CKD Profile FHIR Profile US Core Condition Profile FHIR Resource Condition Resource FHIR Standard FHIR R 4 Standard Added constraints for CKD: • CKD value set • Time stamps • Cause/Etiology • ESRD Indicators • Etc. Added constraints for USA Basic Structure – All Realms

Profile Relationship Diagrams • Profiles can reference other profiles – – Promotes reuse Efficiency Builds a construct to represent a cohesive model Examples: § Chronic Kidney Disease v Supporting evidence represented in other profiles (Other conditions, procedures, etc. ) § Care Plan v Backbone Structure for the IG v Will pull together all the identified CKD (and other) Data elements (CIMs) now represented in profiles v Care Plan structure identifies goals, activities, outcomes by referencing profiles in specific locations • Profile Relationship Diagrams – to study the big picture

Chronic Kidney Disease Condition (V 2. 0)

MCC FHIR Care Plan Profile Relationship Diagram (V 1. 0)

MCC Goal V 0. 1

Goal Questions/Notes • Do we want to “require” “Start” • When goal pursuit begins • Description vs Measure • Description: Human-readable and/or coded description of a specific desired objective of care, such as "control blood pressure" or "negotiate an obstacle course" or "dance with child at wedding“ • Measure: Commonly LOINC (e. g Systolic BP, Weight) something that COULD be described in quantitatively • Why is Procedure Not in goal. addresses? • US Core Goal Questions/Notes (see email)

Goal Questions/Notes • Do we want to “require” “Start” • When goal pursuit begins • Description vs Measure • Description: Human-readable and/or coded description of a specific desired objective of care, such as "control blood pressure" or "negotiate an obstacle course" or "dance with child at wedding“ • Measure: Commonly LOINC (e. g Systolic BP, Weight) something that COULD be described in quantitatively • Why is Procedure Not in goal. addresses?

US Core Goal Questions/Notes • Referencing US Core Profiles within US Core Goal (and others) • Is due. Date "Must Support", even though the due slice is not Must Support? Does this mean if you have "due", you must have a date? – Yes • Is due. Duration precluded? – Yes – slice is closed

Questionnaire/Questionnaire Response Integration • Questionnaire - May come in via 1. Care. Plan. instantiates. Canonical. Questionnaire 1. 2. What does it mean to have a questionnaire (without responses) that is “adhered to in whole or in part by a Care. Plan. ”? Care. Plan. supporting. Info. Reference. Questionnaire Does it make sense to have a questionnaire without responses within a Care Plan? 2. Care. Plan. supporting. Info. Questionnaire. Response 3. Care. Plan. supporting. Info. Reference. Condition. evidence. detail. Questionnaire. Response 4. Care. Plan. supporting. Info. Reference. Observation. has. Member. Questionairre. Response • This project will describe integration via 1, 2, and 3. We will not preclude 1

MCC FHIR Care Plan Profile Relationship Diagram (V 0. 2)

QQR Possible Integration • Provide narrative guidance within the profile rules wrt questionnaire integration point recommendations • Encourage 1 integration point? • Preclude given integration points? • Do not create multiple profiles to cover questionnaires of interest to MCC (focusing on CKD initially) • Rather….

QQR Possible Integration • Provide narrative guidance of pointing to tooling, such as: – FHIR SDC LHC SMART App § Creates form and the instance of FHIR QQR (example: https: //loinc. org/81526 -6/) – LOINC Questionnaire API (see "Questionnaire") § Can return a LOINC panel as a FHIR questionnaire using the canonical LOINC URI pattern for questionnaires § But. . uses Argonaut Questionnaire IG (based on FHIR STU R 3) • Refer also to Structured Data Capture for further guidance • Provide table of LOINC panel codes of interest

QQR Possible Integration – Example table LOINC Code Long Common Name 63922 -9 Are you considering quitting smoking during the next 6 months [PLCO] 81526 -6 PROMIS short form - cognitive function - abilities subset 6 a - version 2. 0 76700 -4 PROMIS short form - physical function 4 a - version 1. 0 (PANEL) 72055 -7 Vascular access panel [ESRD] 44249 -1 PHQ-9 quick depression assessment panel [Reported. PHQ] 75418 -4 PCORI patient-reported outcomes common measures - core and recommended [PROMIS]

MCC e. Care Plan IG Tour • https: //trifolia-fhir. lantanagroup. com/igs/lantana_hapi_r 4/MCCIG/index. html

MCC FHIR Care Plan Actor Transaction Diagram