ToC+-+Care+Planning+Consensus+Page

include component="page" wikiName="siframework" page="TOC Header"
 * The Care Planning Document is now complete and attested for; considered FINAL and submitted to the ONC...please note the document here[|HIT Enabled Care Coordination 2 8-ONC.docx].**
 * Consensus is now closed!**

Page 5 needs further clarity: "Leveraging existing standards to allow for attachments to care plans..." is confusing. Recommend per comment to remove. Recommend including short definitions of Clinical Summaries, Hospital Discharge Instructions, Hospital Discharge Summaries, etc to clarify when one is used over the other or in what combination. For example, are Hospital Discharge Instructions a part of Hospital Discharge Summaries? Who are they intended for? Should all documents and exchanges of data be used by the patient? While I appreciate the difficulty in coming up with a "leader" or "coordinator" for care, this needs further clarity. Using the Medical Home model is a start; perhaps wording to the effect of WHY both the patient and a designated physician/specialist should have the full record of the patient would be helpful. Perhaps including A, B, C, D data sets for ToC would provide a framework for the purpose of the document. || comments on discussion tab and detail edits I submitted separately considered. As indicated in this final document, I hope to see that next stage process commences soon to provide a robust basis for refinement of a minimal care plan as well as conversation, innovation, and standards development to support a virtual master care plan as indicated in the document version 2.7. || 1. Care Coordination in the title [see Dr. Leftwich's comment] without Care Management (the umbrella term that encompasses care coordination) implies that only the logistical elements of care planning are under consideration. The body of the document now reflects that we are not limiting just to logisitics. Were we to return to "Care Coordination only in the title, It could also be construed by others from this title that only care coordination is of interest to ONC. Perpetuating that title through the public comment period could result in pressure to remove the content on Care Management. Please ask ONC to provide a rationale for limiting the title to Care Coordination. 2. Perhaps we should make a second recommendation to ONC that scope be widened to encompass document title change as well as standards for all care management processes? Professional care managers view the care planning process to involve patient advocacy (including access to needed services and improved self-management through education) as well as encompassing care coordination (logistics) - not the reverse. Many of us feel that if the charge was given to limit our work to care coordination this too should have been (or still should be) open for discussion. 3. Care Planning requires care planners such as Case Managers as well as Care Coordinators. There are financial implications if physicians assume the care planning role currently performed by nurses and social workers. The managing physician will surely benefit by reviewing these care plan elements to ensure medical decisions reflect patient capacity and willingness to implement all components of the care plan and ensuring through that oversight that discrepancies are resolved. Most elements of care plans (see C & D elements of the roadmap) do not need direct (more costly) physician oversight (including in PCMH) as they dont relate directly to diagnosis and treatment - thus they can be capably crafted, supervised and implemented by non-physician Care Professionals especially if adherent to industry standards and local policies and procedures [See remarks by T. O'Malley below]. 4. To the document editor: please review my detail edits submitted separately. || The doc is a very good discussion of issues, but it does not appear to be an actionable recommendation of what data exchange is required. What would ONC do with the document once it receives it? I think it’s unclear whether the document achieves is stated purpose: “It is designed to summarize and articulate required data exchange to enhance the consistency and quality of care coordination across patient’s transitions of care.” “Possible Solutions” sounds very preliminary and not like a recommendation. I **think** that the most concrete recommendations are for the care team and master care plan to be created and included in exchanges, but these don’t stand out from all the rest. It says there should BE a Care Team, but doesn’t propose how to get there from here. The document mentions medical home several times. Are its recommendations limited to cases where PCMH exists? Is it recommending that every patient be in one? It’s not clear what it recommends if PCMH is not in place. In general needs an editorial clean-up before finalization. There are some awkward sentences, missing words, or other typos (beyond those I listed below). There are several questions under “Achievements to Date.” Since there is some uncertainty about the status of several items, these should be resolved or else qualified as W-I-P. I also have similar uncertainty about what is final and what is obsolete, because of the many workgroups and the many documents in each – e.g., standards, IG, data elements -- and what is still developing. Typo (missing word): “made references to current and potential care processes WHICH were impossible to avoid” Typo “the e ToC Initiative” This bullet is an incomplete sentence and hard to understand: “Recognized and established care team appropriate and accommodating dynamic changes to the patient’s individual needs” Typo: “… recommendations by specialists after evaluation of a patient. Should be exchanged in order to update the master care plan ” change to “… of a patient should be exchanged…” Under Open Issues: #3: suggest last sentence be “…require patient participation and smart business rules //to help clinicians perform// the reconciliation process.” I think it needs to be explicit about the clinician’s responsibility in the reconciliation. || ALSO Purpose of document should go first. The "Who Are We" section should be part of a background section following the purpose. Enough information should be provided in purpose so that anyone picking up the document will understand its purpose adequately to make a decision about whether they want to continue reading. || Alliance for Nursing Informatics, AMIA - Nursing Informatics WG ||  ||   || Terrence O'Malley, MD Partners Healthcare Yes with comments Grand vision but needs more description of current state, needs and gaps. Several issues that may be problematic including: coordination across payers: coordination accross multiple providers during a single episode of care; coordination over time; a series of goverance issues need to be addressed such as control and editing of entries (who gets the last word?); standardization of data sources, accuracy, definitions particularly when provided by non-clinical personnel. Most care is provided outside of the physician-hospital setting, there are many providers in addition to the patient that are essential for care and are not yet fully represented here.
 * **Name** || **Organization** || **Endorsement (yes/no)** || **If No, what can be done to make it Yes?** ||
 * John Quinn || Accenture ||  ||   ||
 * J. Michael Fitzmaurice || Agency for Healthcare Research and Quality || Yes ||  ||
 * Robin A. Barnes || Agency for Healthcare Research and Quality(AHRQ) ||  ||   ||
 * Derrick Evans || Allscripts ||  ||   ||
 * Anne Diamond || American College of Obstetricians and Gynecologists (ACOG) ||  ||   ||
 * James Scroggs || American College of Obstetricians and Gynecologists (ACOG) ||  ||   ||
 * Thomson Kuhn || American College of Physicians (ACP) || Yes ||  ||
 * Harry Rhodes || American Health Information Management Association (AHIMA) ||  ||   ||
 * Denise Maxwell-Downing || AORN (Association of periOperative Registered Nurses), IHE ||  ||   ||
 * Seonho Kim || ApeniMED (formerly MEDNET) ||  ||   ||
 * Greg Chittim || Arcadia Solutions ||  ||   ||
 * Mary Lynam || Argus Health Systems ||  ||   ||
 * Amber Broadwater || IOS Health Systems ||  ||   ||
 * Lin Wan || Axolotl Corp. ||  ||   ||
 * Coletta Dorado || AZZLY ||  ||   ||
 * Jeffrey Ice || AZZLY ||  ||   ||
 * Tara Jacquet || BH&A Ins. Services ||  ||   ||
 * Sriram Bharadwaj || Business Strategix Inc ||  ||   ||
 * David Lenhart || Cal eConnect ||  ||   ||
 * Paula Gwyn || CareTech Solutions ||  ||   ||
 * Gary Dickinson || CentriHealth || Yes ||  ||
 * Greg Turner || CGI ||  ||   ||
 * Justin Austin || Clopton Clinic ||  ||   ||
 * Terri Skalabrin || Colorado Regional Health Information Organization (CORHIO) ||  ||   ||
 * Michael L. Glickman || Computer Network Architects, Inc. ||  ||   ||
 * John Odden || Coto Partners, AIIM, CGC, C4UH ||  ||   ||
 * Dr John Haughton || Covisint ||  ||   ||
 * Rachelle Blake, PA, MHA || CTG Healthcare Solutions / Omni Micro Solutions; HIMSS Advocacy and Public Comment Workgroup ||  ||   ||
 * Dalana Ostlie || Deaconess Medical Center ||  ||   ||
 * Chris Doucette || Deloitte ||  ||   ||
 * Randolph Sanks, MBA || Deloitte (Health and Life Sciences) ||  ||   ||
 * David Parker, MD || Department of Defense/Evolvent Technologies ||  ||   ||
 * Tom Dawson || Dispersive Medical ||  ||   ||
 * Stephen Hufnagle || DoD Military Health System ||  ||   ||
 * Jim Hansen || Dossia Consortium ||  ||   ||
 * Elliot B. Sloane, PhD || Drexel University School of Biomedical Engineering //Center for Healthcare Information Research and Policy (CHIRP)// ||  ||   ||
 * Kyle Meadors || Drummond Group Inc. ||  ||   ||
 * Hari Ramachandran || Enable Healthcare Inc ||  ||   ||
 * Rahul Dewan || Enable Healthcare Inc ||  ||   ||
 * Peter DeVault || Epic ||  ||   ||
 * Vassil Peytchev || Epic ||  ||   ||
 * Thomas Giannulli MD, MS || Epocrates ||  ||   ||
 * Larry Garber, MD || Fallon Clinic/SAFEHealth || Yes || However, there ought to be a paragraph encouraging integration with clinical decision support to promote evidence-based care plans and to help ensure that the Master Plan is indeed followed. ||
 * Joel Amoussou || FEI Systems on behalf of SAMHSA ||  ||   ||
 * Ken Lord || FireStar Software, Inc ||  ||   ||
 * Mark Eisen || FireStar Software, Inc ||  ||   ||
 * John B. Williams || Garden State Health Systems Inc / Health-ISP.com ||  ||   ||
 * John Moehrke || GE Healthcare ||  ||   ||
 * Ruth Berge || GE Healthcare ||  ||   ||
 * Patricia MacTaggart || George Washington University ||  ||   ||
 * Mark Braunstein, MD || Georgia Institute of Technology ||  ||   ||
 * Steve Rushing || Georgia Institute of Technology ||  ||   ||
 * Gregory L. Smith || Greg Smith and Associates (KHIN, KHIE) || Yes || Incorporate changes and comments from Holly and Russ ||
 * Susan Johnston || GSI Health ||  ||   ||
 * Thompson H. Boyd, III, M.D. || Hahnemann University Hospital ||  ||   ||
 * Joan Duke || Health Care Information Consultants, LLC ||  ||   ||
 * Durwin Day || Health Care Service Corporation ||  ||   ||
 * Jaime Estrada || Health Information Network of Arizona ||  ||   ||
 * Lindsey Hoggle || Health Project Partners, LLC || Yes || As per other comments, wordsmithing and document clean up are needed. Appreciate the frequent reference to patient centered care and engagement. Given the need for a huge cultural shift to occur, I think clarity for patient self-management (within the patient's capability) needs to be stated earlier in the document. The comment of "....in cooperation with the patient (Page 3/Master Care Plan) could be more clearly articulated. WE all know the message, but patients and other providers need to understand that given decision support tools, the goal is for the patient to make an informed choice with their provider.
 * Simpson William || Healthland ||  ||   ||
 * Leslie Kelly Hall || Healthwise || YES ||  ||
 * Susan Nedza MD || HealthyCircles, LLC. || Yes, with modifications || Please consider comments which were sent separately regarding word choice and questions including identifying the breadth of participants, ensuring that "barriers" are identified as "challenges" and "opportunities". I also support including a more active description of the needs for patient access to include "view, interact, verify and download" . Please see specific comments on Open Issues regarding audit trails and the fact that this is indeed a part of a medical record and subject to the rules and regulations about storage and access. ||
 * Anna Poker || HHS/HRSA ||  ||   ||
 * Louise V. Fryer, RN, MS, PMP || Highmark Blue Cross Blue Shield ||  ||   ||
 * Penny Probst || Highmark Blue Cross Blue Shield ||  ||   ||
 * Joyce Sensmeier || HIMSS ||  ||   ||
 * Audrey Dickerson || HIMSS and IHE/PCC technical representative ||  ||   ||
 * Sandra Schafer || Holon Solutions || Yes || I appreciate the work that has gone into the creation of this document and believe it is very well written. My comment is around patient centered medical homes. While mentioned under the "Master Care Plan" section of the document, I believe it is important to reference the work that has gone into the development of PCMHs particularily around selection of patients that can most benefit from care coordination, evidence based care and reporting of results/outcomes. Unrelated to the above comment; who is going to take a stance on the issue of "ownership" and how much progress can we really make with this issue unresolved? ||
 * Mary Moewe || Iatric Systems ||  ||   ||
 * David Cheng || IBM ||  ||   ||
 * Aaron Stranahan || ICA ||  ||   ||
 * Adora Bruce || ICA ||  ||   ||
 * Mayuri Patel || ICA || YES ||  ||
 * Tim Dunnington || ICA ||  ||   ||
 * Keith W. Boone || IHE PCC Domain ||  ||   ||
 * Michael J. McCoy, MD || IHE PCC, ACOG, Catholic Health East ||  ||   ||
 * Scott Serich || IJIS Institute ||  ||   ||
 * Rosa Aleman || Independent Registered Nurse working as a Women Health Educator in Family Planning and Foreign Medical Graduate ||  ||   ||
 * Susan E. Campbell, PhD, RN || Care Management Professionals || YES, with
 * John Donnelly || IntePro Solutions, IHE || No || There are a considerable number of edits to the distributed document. I concur with the inclusion of these edits but some of the comments are in the form or a question which need resolution before a consensus can be achieved. I also have one suggested edit in the "Patient Access to Portable Health Information" paragraph. Namely to remove the clause "via a web based portal" which I feel is a very limiting statement in the document as well as being more about the implementation architecture than the functional requirement... and with that does not reflect the various technical architecture options available today. I suggest that a cleaned-up copy be circulated following today's call. ||
 * Cyndalynn Tilley || Intermountain Healthcare ||  ||   ||
 * Laura Heermann Langford || Intermountain Healthcare ||  ||   ||
 * David E. Clark || IRIS Partners, LLP ||  ||   ||
 * Larry Wolf || Kindred Healthcare ||  ||   ||
 * Sajid Ahmed || L.A. Care Health Plan – HITEC-LA ||  ||   ||
 * Jeff Bloemker || Lewis And Clark Information Exchange ||  ||   ||
 * Amy Knopp || Mayo Clinic ||  ||   ||
 * Corey Spears || McKesson ||  ||   ||
 * Holly Miller, MD, MBA || MedAllies || No || Please incorporate previously sent edits, also further edits whcih I will bring up in the call today. Thanks ||
 * Vasu Iyengar || MedAZ.net, LLC ||  ||   ||
 * Adrian Gropper || MedCommons ||  ||   ||
 * Mark Bamberg || MEDfx ||  ||   ||
 * Eric Heflin || Medicity ||  ||   ||
 * Luann Whittenburg || Medicomp System, Inc. || Yes ||  ||
 * Fred Buhr || Metasteward LLC ||  ||   ||
 * Paul Edge || Microsoft Corp ||  ||   ||
 * Konda Mullapudi || Misys Open Source Solutions (MOSS) LLC. || Yes ||  ||
 * Rick A. Moore || National Committee for Quality Assurance (NCQA) ||  ||   ||
 * Lynne Gilbertson || NCPDP ||  ||   ||
 * Teresa Strickland || NCPDP ||  ||   ||
 * John Klimek R.Ph. || NCPDP - National Council for Prescription Drug Programs ||  ||   ||
 * Annamarie Saarinen || Newborn Coalition ||  ||   ||
 * Tom Foley || NextEnt, LLC ||  ||   ||
 * Robert Barker || NextGen Healthcare ||  ||   ||
 * Steven Saitsky || NextGen Healthcare ||  ||   ||
 * Russell B. Leftwich, MD || Office of eHealth Initiatives, State of Tennessee || Yes || The document has carried the title HIT Enabled Care Coordination in a Reformed Health Care System as was consistent with our intial charge, care planning being a subset of that. This cannot be changed. ||
 * Kimberly Tooles || Onyx Home Health Care, LLC. ||  ||   ||
 * Lola McCune || Onyx Home Health Care, LLC. ||  ||   ||
 * Robert Worden || Open Mapping Software ||  ||   ||
 * Brian Ahier || Gorge Health Connect, Inc. || Yes ||  ||
 * Elizabeth M. Evans || PANDA and Associates, LLC ||  ||   ||
 * C John Torontow MD MPH || Piedmont Health Services ||  ||   ||
 * Elaine A. Blechman || Prosocial Applications, Inc. ||  ||   ||
 * Teresa M. Mota, BSN, RN, CALA || Quality Partners of Rhode Island ||  ||   ||
 * Freida Hall || Quest Diagnostics, Inc. ||  ||   ||
 * Ken McCaslin || Quest Diagnostics, Inc. ||  ||   ||
 * Bob DeAnna || Recursion Software ||  ||   ||
 * Will Ross || Redwood MedNet ||  ||   ||
 * Charles Hewitt || Rhode Island Quality Institute ||  ||   ||
 * Charles Hewitt || Rhode Island Quality Institute ||  ||   ||
 * Gary Christensen || Rhode Island Quality Institute ||  ||   ||
 * Todd Treiber || Sage Healthcare ||  ||   ||
 * Lane Chambers || SAIC ||  ||   ||
 * Vera Blanc || Sandlot ||  ||   ||
 * Sherry Selover || Selover Company ||  ||   ||
 * Ernest Grove || SHAPE HITECH, LLC ||  ||   ||
 * Lester Keeper Jr. || SHAPE HITECH, LLC ||  ||   ||
 * David Tao || Siemens || Yes || //Changed my "no" to a "yes" following the call on Monday 9/19. I still have concerns and corrections as expressed below, but agree with the intent and the streamlining done on the call, so I am OK with it being given to ONC as important items for their consideration (without purporting to be prescriptive).//
 * Doug Pratt || Siemens ||  ||   ||
 * Lorre Pacheco || Sunquest Information Systems ||  ||   ||
 * Mark T. Palen, PMP, CPHIMS || System Administrative Services, L.L.C. || Yes ||  ||
 * Thomas P. Caruso || T.P. Caruso & Associates || No. || I'm not clear about how the Office of the National Coordinator of Health Information Technology can be proposing standards of care planning. I understand the ability of this organization to propose standards to an electronic care plan, but a lot of this document is about the actual care, not specifically about IT issues associated with care. I propose the document be focused on the HIT issues, pulling out any recommendations about how care should be planned and managed. For instance, care coordination, though very important, is not an HIT issue.
 * Sri Koka || Techsant Technologies ||  ||   ||
 * Betty Levine || Telemedicine Advance Technology Research Center/Department of the Army ||  ||   ||
 * Ollie B. Gray || Telemedicine Advance Technology Research Center/Department of the Army ||  ||   ||
 * Mara Robertson || Tennessee Primary Care Association (TPCA) ||  ||   ||
 * Virginia Lorenzi || The NewYorkPresbyterian Hospital ||  ||   ||
 * Philip DePalo || Towson University ||  ||   ||
 * Yeong-Tae Song || Towson University ||  ||   ||
 * Gregory L. Alexander PhD, MHA, MIS, RN || University of Missouri,
 * Catherine Hoang || VA ||  ||   ||
 * Holly Miller || VA ||  ||   ||
 * Mike Lincoln || VA ||  ||   ||
 * Patty Greim || VA ||  ||   ||
 * Sarah Maulden || VA || Yes || with edits per Dr. Miller on consensus call of 9/13/11 ||
 * You-Ying Whipple || VA ||  ||   ||
 * Rob Lecker || Vecna Technologies ||  ||   ||
 * Michael Meyer || WellPoint ||  ||   ||
 * Theresa (Terry) M. Hearn || WellPoint ||  ||   ||
 * Albert Llanes || ZyDoc ||  ||   ||
 * Matthew Bouchard || ZyDoc ||  ||   ||

include component="page" wikiName="siframework" page="space.template.inc_contentleft_end"