Patient Care Coordination

Tone SoutherlandTone Southerland Greenway Medical TechnologiesGreenway Medical TechnologiesCo-chair, IHE PCCCo-chair, IHE PCC

Marcia VeenstraMarcia VeenstraSenior Health Inc.Senior Health Inc.Co-chair, IHE PCC Nursing Sub-committeeCo-chair, IHE PCC Nursing Sub-committee

What is PCC?

• Scope includes:– Integration issues that cross providers, patient

problems or time.

– General clinical care aspects such as• Document exchange

• Order processing

• Coordination with other specialty domains

– Address workflows and the integration needs of speciality areas without a separate domain within IHE

A content profile is…

• A sharable information component that can be exchanged..– Within an HIE (XDS)– Via Media or USB Device (XDM)– Via Reliable Messages (XDR)

• Human Readable– CDA Level 1 and 2

• Machine Processable– CDA Level 3

• A Library of Reusable Parts

Library of Templates

Documents

LAB

Problems

Vitals

Result

Problem

Obs

SeverityReferral

XPHR Vital

Sections Entries Parts

5

PCC Profiles

Medical Summaries

Emergency Department

Referral

ExchangingPHR

Content

AntepartumCare

Summary

EmergencyDepartmentEncounter Summary

FunctionalStatus

Assessments

2005-062005-062006-072006-072007-082007-082008-09 2008-09 2009-102009-10 I

nte

grat

ion

Con

ten

t

Query for Existing Data

AntepartumRecord

ImmunizationRegistryContent

Care Management

Request for Clinical

Guidance

Labor and Delivery Record

Patient Plan of Care

EMS Transfer of

Care

Labor and Delivery Record

• The LDR Profile provides information to the health care providers about the labor and delivery and the newborn in an in-patient setting

• Useful for – Transfers of care in the in-patient setting (OR

or NICU)– Post-partum outpatient care

Emergency Responder Pre-Hospital Care Report

• The ER-PCR Profile computerizes crash victim emergency contact information (ECON) and personal health record (PHR) data, thereby helping on-site Emergency Responders improve post-crash emergency healthcare and outcomes for crash victims

Query for Clinical Guidance

• The QCG Profile provides a way to communicate decision support inputs and outputs between HIT and CDS systems.

• This provides a way for HIT applications to quickly incorporate CDS capabilities from a variety of sources into different workflows

Detailed Scores/Assessments

• This white paper provides a generic section for Score Systems and Assessment Scales separating the structure from the score specific details

• Uses HL7 V3 Patient Care – Care Provision – Assessment Scale Topic DSTU as foundation

Nursing Objectives

• SubCommittee Objectives:– Recognize currently nurses do not have

cross enterprise nor intra-enterprise interoperability documentation as part of their electronic workflow

– Describe expectations of care outcomes related to interoperable health records

– Provide interoperable documentation for nursing practice in all specialties

Desired Nurse/Patient Outcomes

• Availability of patient and clinical information prior to admission/transfer

• Early intervention minimized complications

• Complete clinical information promotoes safety and improved outcomes

• Continuity of interdisciplinary plans of care using nursing data promotes safer transfers of care, evidence for outcomes improvements and patient satisfaction

Nursing Roles

• Treating the human response along the health – illness continuum– Support health maintenance and disease

prevention – Perform patient care and treatment– Educate for prevention of illness and

promotion of health and wellness– Collaborate with multiple disciplines

Coded Nursing Documentation

• Health Assessment– Vital signs and measurements, including Pain– Body sounds, including Heart, lung, abdomen– Internal and external patient fluid management– Activities of daily living

• Plan of Care

• Educate the patient and family• Disease, medication and treatment management• Lifestyle changes and disease prevention• Safety in health and illness• Pain management

For Further Information

• PCC on the wiki:– http://wiki.ihe.net/index.php?title=Patient_Care_Coordination

• PCC Tech Google Group:– http://groups.google.com/group/pcctech

• PCC Plan Google Group:– http://groups.google.com/group/pccplan