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Patient Care Coordination

Patient Care Coordination

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Patient Care Coordination

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  1. Patient Care Coordination Tone Southerland Greenway Medical Technologies Co-chair, IHE PCC Marcia Veenstra Senior Health Inc. Co-chair, IHE PCC Nursing Sub-committee

  2. 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

  3. 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

  4. Library of Templates Documents Sections Entries Parts Referral Problems Problem Severity XPHR Vitals Vital LAB Result Obs

  5. PCC Profiles Patient Plan of Care Labor and Delivery Record EMS Transfer of Care Medical Summaries FunctionalStatusAssessments Emergency Department Referral ExchangingPHRContent EmergencyDepartmentEncounter Summary AntepartumCare Summary AntepartumRecord ImmunizationRegistryContent Integration Content Query for Existing Data 2005-062006-072007-082008-09 2009-10 Care Management Request for Clinical Guidance

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. For Further Information • PCC on the wiki: • • PCC Tech Google Group: • • PCC Plan Google Group: •