Care+Coordination+and+eReferra

**IHE Australia - Patient Care Working Group** Patient Centered Coordination Plan (PCCP)
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= News: = = IHE international Patient Care Co-ordination Technical Committee progresses IHE Australia's initial work on a patient centred coordination plan =

A key feature of the profile is to support the sharing of structured plans across enterprises and for the information contained in these plans to be able to support coordination of care. 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.

The resultant profile can be expected to:
 * define a set of documents to support a care coordination workflow (Coordination Plan, Plan Task and Task Report)
 * use of XDS and related profiles to support creation of shared coordination plan documents and other elements of care coordination

The current draft of the profile can be downloaded at A full set of working documents is available from the IHE FTP Site [|here]

This work is being progressed and all are welcome to participate or monitor progress on:

Join this list: [] Join this list: [|http://IHE.net.au/mailman/listinfo/patientcare_ihe.net.au]
 * On the IHE international Patient Care Coordination discussion list
 * On the IHE Australia Patient Care List

To attend the teleconference.[| dial in details] (via Webex, headset-no charge, or Australian dial-in)
 * Via regular weekly international teleconferences _ Tuesday 8.00am (Eastern Australian Summer Time - Canberra)

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, building on the work undertaken at a national IHE care coordination and ereferral workshop last December.

Current Issues under discussion:
Whether the coordiination plan should consist of discrete component documents dealing with each task: How meta data can be attached to the task documents to enable software to identify the state of the task (goal on target or not on target)

Harmonisation and CDA modelling
The Patient Centred Care Coordination plan should be harmonised with the IHE PPOC profile development, and work underway in the HL7 Community Based Collaborative Care group and the HL7 Patient Care working group. There has been much discussion about the use of the PPOC document to hold the Coordination Plan content. An initial investigation shows that this should be feasible. We will need to pay attention to semantics and document a clear and comprehensive set of constraints and guidelines relating to the use of the PPOC document to ensure that the requirements for coordination outlined in this profile are covered. There are some differences in terminology that would also need to be taken into account. There are subtle but important differences in the semantic content of the plans that will need to be addressed – PCCP treats Tasks as self contained entities, with a clear outcome associated with each task. Tasks are organised within Goals, but Goals are not the main focus of tracking – Tasks are. The intention here is to allow distribution of work to a care team, and for members of the team to be able to act independently (but in a cooperative and coordinated fashion) and to submit trusted reports on progress against their tasks. The aim is to provide efficient support for the Care Coordinator, allowing them to quickly identify which Tasks are not on track so that they can focus their attention on those tasks, modifying the Coordination Plan as required. PPOC has two entities that relate to achieve a similar result, “Expected Outcomes” and “Orders”. This is a subtle but significant semantic difference that should be discussed and both profiles clarified. The PPOC relates expected outcomes to goals, and the tracking of the plan is then a matter of re-assessing progress against the desired outcomes (goals), and modifying the plan, either by changing the expected outcomes (because they are no longer realistic, or have been achieved, to pick some possible examples) or by changing the orders (for instance, to provide more intensive intervention in order to achieve a desired outcome). The difference between these approaches is not irreconcilable, but there is quite a bit of work required to do so. The editor of the PCCP profile is willing to try, but will not be able to achieve this without cooperation and assistance.

Further background and description of the proposed profile and useful links

Further information: Jon Hilton pcc@ihe.net.au Peter MacIsaac admin@ihe.net.au (0411403462)