Patient Centered Coordination Plan (PCCP)

Profile background

Care planning or co-ordination is being more widely used as a tool for improved management of complex, chronic and multifaceted healthcare problems.

The key features of care co-ordination involve:
  • the appointment of a care coordinator
  • the development of a care plan,
  • creation of a formal care team to address each of the healthcare issues or tasks,
  • communication of care plan and other relevant events between members of this team,
  • followup on the process and outcomes of the care delivered.
  • active patient involvement
  • engagement with other healthcare providers and events outside the team

IHE's patient care co-ordination technical committee is currently working on a profile to both utilise and extend the existing and implemented Cross Enterprise Document Share (XDS) profile (part of IHE Infrastructure Profile set) to support patient centred care co-ordination.

A key feature of the profile is to support the sharing of structured care plans across enterprises and for the information contained in these plans to be able to support care planning and delivery. The early work on this profile occurred in Australia in late 2009 and is now being taken up by the IHE international Patient Care Co-ordination (PCC) technical committee.

This profile should developed and tested in 2010 and be ready for vendors to demonstrate in IHE showcases and used in products by early 2011. Current activity is focused on the drafting of the technical profile. Members of the Australian ehealth community are welcome to contribute to the development of this profile.

The lead co-author, Jon Hilton (Precedence Healthcare and HISA representative at IHE Australia) said "This profile will support communication across care teams working in different healthcare environments and IT systems". Building on existing IHE profiles which support both point to point health document delivery and ongoing availability of health information accessed by a healthcare information registry, this profile will integrate the processes of creation of a care plan, referral to external healthcare providers, and ongoing communication and updates as the patient receives treatment.

Dr. Peter MacIsaac (HP Enterprise Services and IHE Australia board member) is a co-author of the proposal. He commented that this profile will support care coordination where it is not possible or desirable for all members of the care team to adopt the same clinical information system for care coordination, as tends to happen with current models of care management. IHE's use of a standards based approach and liaison with healthcare professionals and their organisations allows for the definition of the key "actors" and specification of the interactions between them. How each "actor" works internally (ie the functions and performance of the care management software) is driven by industry best practice and meeting user needs in the usual commercial models. "There is no intention to interfere with the competitive industry processes to deliver useful products; the care coordination profile will however support interoperablity" said Dr MacIsaac

Building on IHE's existing infrastructure is the key to success, according to Chris Lindop (GE Healthcare and IHE international radiology co-chair) who is the third co-author of the proposal. Chris has acted as the liaison between IHE Australia and the international Patient Care Committee. Chris recently hosted a seminar on IHE Cross Enterprise Document Share (XDS) and pointed out that while IHE XDS is not a fully developed health information sharing architecture, it does provide all the core components that could be used to build working systems, using todays technology with components being provided by multiple vendors. The existence of core components relating to document transport, storage and indexing, patient identity, referral management, subscription and security enable users to progress to implement additional functionality as feasible components and within a short timeframe from conceptualisation to implementation. Where this profile is implemented in a working XDS model other information such as lab results, hospital discharge summaries, diagnostic images and medications will also be available to the care team using the same infrastructure used to publish and deliver. Chris Lindop stated 'IHE provides a framework for handling health communication on a common platform, it is not necessary to have different systems for each type of communication. This brings down costs and creates a significant value add for users".

Vince McCauley (Chair of IHE Australia, and immediate past president of the Medical Software Industry Association) welcomed this initiative and noted that this is an example of leading edge Australian eHealth developments arising from collaborations of users and vendors, being embraced by international standards and eHealth implementation groups. "In this case, Australia has provided input from a decade of development around care coordination and chronic disease management, largely sponsored by the Commonwealth and State Governments, and implemented by our health IT sector. He concluded "A particular attraction of the IHE model for record sharing is that it is capable of being implemented regionally,and then integrated through a federated model as time and uptake proves the value of these tools for patient care and healthcare efficiency."

Background on IHE.

IHE is an international organisation made up of health IT system users and vendors where collaboration occurs on solving practical health communication problems. IHE provides a standards based health interoperability architectural framework and it works for those health sectors (e.g. radiology, pathology) and countries (e.g. USA, Canada, Austria, Italy, France) where national authorities are working with industry via IHE to deliver health communication systems. The key the success of IHE has been a iterative development of interoperability profiles based on existing health IT standards such as HL7, Web Services, DICOM. These profiles then can be extended as user and industry requirements emerge. Each year IHE prioritises a number of new profiles or extensions for development. Australia has used this approach to create standard implementation profiles of HL7, and more recently the industry, NEHTA and DoHA partnership on developing profiles for webservice messaging (PIP Secure Messaging).

Tackling a health communication problem the IHE way starts with development of an implementable profile which meet user requirements, select standards, provide any missing components such as terminology, and remove ambiguity. IHE Australia has proposed a profile to tackle care coordination and e-referral. This proposal has been short listed and will be followed up by a set of storyboards/usecases which will be evaluated by the IHE Patient Care Committee (international) for inclusion or other followup

Archive of profile drafts

Go to profile proposal sandpit


Go to storyboard sandpit

Background: for the December 9th Workshop Documents:

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external image msword.png Care coordination usecases v-9.doc
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PCC Profile Proposal Chronic Care Coordination.ppt
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Useful Links re Patient Care and Care Co-ordination

IHE Patient Care Coordination - Technical Profile

IHE Medical Home whitepaper draft - wiki

Draft template for Patient Care Prolile - link