HL7 FHIR Connectathon Care Plan Track Outcome Summary

HL7 FHIR Coectatho Care Pla Track Outcome Summary Jauary 2017, Sa Atoio, TX 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office.

Drivers for Care Pla Chroic diseases burde o healthcare Care fragmetatio i a multi-providers healthcare ecosystem Compoudig poor health outcomes Value-based healthcare High complexity, high costs Poor health outcomes Better quality Lower costs Better patiet egagemet ad self-maagemet Better patiet satisfactio Care pla is oe of the ONC top techology capability priorities for alterative paymet model 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office. 2

Participatio BIG turout, filled 2+ tables! Active collaboratio with Cliicias o FHIR, cliicia attedees Orgaizatios: Academy of Nutritio ad Dietetics Allscripts Duke Ceter for Health Iformatics Healthcare Services Platform Cosortium (HSPC) Itermoutai Healthcare IBM IterSystems ONC Qvera SAMHSA VA Ad others.. 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office. 3

Primary Use Case Sceario Type II Diabetes Mellitus Storyboard Three related CarePla resources Primary Care Provider (PCP) Dietitia Podiatry Cotet icludes: CarePla, CareTeam, Goals, Problems & Health Cocers, Pla activities (medicatios, referrals, activities for the patiet) 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office. 4

Cliet/Server Coectios All testig with FHIR 1.8.0 Allscripts TouchWorks FHIR cliet ios app: CareKit o FHIR (prototype by Dave C) Servers: HSPC, IBM Qvera Iterface Egie cliet Servers: Allscripts, HSPC, IBM usig OAuth2 Servers: Allscripts, HSPC HSPC Server otificatio of CarePla chages Email otificatio of add/update 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office. 5

ios CareKit o FHIR to HSPC Itervetios Assessmets 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office. 8 Care Team

Patiet Voice Sceario The purpose of this care pla sceario o Patiet Voice is to illustrate the commuicatio flow ad documetatio of a care pla betwee a patiet, his or her primary care provider or other care team members. Specifically we show how iformatio geerated by the patiet about their health goals, care prefereces ad priorities ca be shared so that the patiet s voice ca be icluded i the care plas created by care team members. Cotact: Lisa Nelso This sceario would be relevat for: EMS Services ER visit Nursig Home Primary Care Post Acute Care Palliative Care Orga Doatio 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office. 10

Coclusios ad Next Steps Cotiue to expad sample CarePla resources with cliically valid data https://github.com/cliical-cloud/sample-careplas Dieticia ad Podiatry specialists Next Steps: Subscriptio to chages Schedulig Procedure request Diagostic request Termiology support Recocile multiple plas Access patiet goals from PHR 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office. 11

Care Pla Track Refereces Coectatho track wiki, Ja 2017 Cliicia o FHIR, Care Pla track http://wiki.hl7.org/idex.php?title=cliicia_o_fhir Jauary_2017,_Sa_Atoio Type 2 Diabetes Storyboard http://wiki.hl7.org/idex.php?title=201701_care_pla https://github.com/cliical-cloud/sample-careplas/raw/master/ Care%20Pla%20Storyboard%20-%20Diabetes%20Mellitus.pdf Sample FHIR resources for Diabetes CarePla https://github.com/cliical-cloud/sample-careplas 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office. 13

Burdes of Chroic Diseases Icreasig prevalece of chroic diseases Nearly 80% of US workers have at least oe chroic coditio ad 55% have more tha oe chroic coditio * Patiets with multiple chroic coditios cost up to 7X as much as patiets with oly oe chroic coditio ** Australia Bureau of Statistics (ABS). Natioal Health Survey: Summary of Results, 2007-2008 (Reissue) Cat No 4364.0 Commowealth of Australia, Caberra. 2009 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office. 14

Poor health outcomes Chroic coditio patiets are maaged by multiple providers from multiple orgaisatios Survival aalysis of icreasig umbers of chroic coditios ad risk mortality.4 Outcomes of chroic coditio maagemet remai relatively poor: 1.0 Reasos for outcomes: 0.9 0.8 Survival Probability Icreased mortality Icrease readmissios Poor quality of life 0.7 0.6 0.5 Poor care coordiatio 0.4 - Complex workflow 0.3 - Absece or iefficiet ad ieffective0.2 coordiatio 0.1 Poor patiet egagemet 0.0 - Low or poor compliace 0 1 2 3 4 5 6 7 8 9 10 11 12 13 - Educatio & self care support Time years Low techology maturity No Chroic disease 3-4 chroic diseases > 5 chroic diseases - No/low care coordiatio ad workflow Reproduced from the followig data source: Australia Logitudial Study of Agig Ltd. maagemet support Adapted from the Joural of Epidemiology ad Commuity Health, 2010:64(12): 1036-42 with permissio of BMJ Publishig Group Ltd - Poor usability 2015 Health Level Seve Iteratioal. All Rights Reserved. HL7 ad Health Level Seve are registered trademarks of Health Level Seve Iteratioal. Reg. U.S. TM Office. 15