Patient Care Coordination
Care Coordination supports the Cycle of Care.
This guide currently excludes definitions of the various parts of the Cycle of Care, please see a practitioner for detailed description.
The following guides are designed around the cycle of care:
Assessment and Patient Summary
Will often be referred to as Care Plans by practitioners and be combined with a patient summary. When shared with another provider this will often include a referral. In this section assessments and patient summaries are considered supporting information for referrals, referrals are covered separately.
Specifications
Current API specifications focus on the combination of assessment and patient summary with a referral. These are covered in the Referral section.
Assessment
Guidance
- PRSB Standards
- About Me About Me information is the most important details that a person wants to share with professionals in health and social care. This information might include how best to communicate with the person, how to help them feel at ease or details about how they like to take their medication.
- US National Library of Medicine - LHC FHIR Tools Contains numerous assessments definitions which can be viewed via LHC Forms app (see Creating Forms)
Frameworks and Implementation Guides
- Document Sharing Describes methods of sharing reports in a variety of formats including: PDF and FHIR Document.
- Reporting can also make use of Questionnaires and Structured Data Capture for sending structured report data.
Patient Summary
Guidance
- PRSB Standards
- International Patient Summary This is a FHIR Document which contains a snapshot of the patients record.
Plans and Goals
This section on Care Plans excludes patient summary, assessments and referrals which are covered in separate sections.
Frameworks and Implementation Guides
- IHE Dynamic Care Team Management (DCTM) Provides the means for sharing care team information about a patient’s care teams that meet the needs of many users, such as providers and patients. See Care Plans, Episodes and Care Teams for example implementation.
- IHE Dynamic Care Planning (DCP) The Dynamic Care Planning (DCP) Profile provides the structures and transactions for care planning, creating, updating and sharing Care Plans that meet the needs of many, such as providers, patients and payers. Care Plans can be dynamically updated as the patient interacts with the healthcare system. FHIR® resources and transactions are used by this profile. See Care Plans, Episodes and Care Teams for example implementation.
Patient Administration
Within an acute setting, care will often be managed via stays or episodes. An overview of this can be found in FHIR Administration Module. This is mainly supported by HL7 v2 Admission, Discharge and Transfers standard.
Monitoring (and Encounters)
Frameworks and Implementation Guides
IHE QEDM - The Query for Existing Data for Mobile Profile (QEDm) supports queries for clinical data elements, including observations, allergy and intolerances, conditions, diagnostic results, medications, immunizations, procedures, encounters and provenance by making the information widely available to other systems within and across enterprises. It defines a transaction used to query a list of specific data elements, persisted as FHIR resources.
Personal Health Device (PHD) IG - defines standards for sharing information from personal healthcare devices (heart rate monitors, step trackers, etc.) using FHIR - either directly or via intermediaries. While not all relevant devices will support this standard, a consistent way of handling data from those that do should be useful.
Engagement
Guidance
Frameworks and Implementation Guides
- Questionnaires and Structured Data Capture Covers methods which can be used to report PROMS using FHIR QuestionnaireResponse.
- Quality Measure Implementation Guide - Is a US guide which defines standards for sharing clinical quality measures electronically, allowing defining and sharing measures related to patient activity and appropriate clinical interventions related.
Reporting (and Documentation)
Frameworks and Implementation Guides
- Document Sharing Describes methods of sharing reports in a variety of formats including: PDF and FHIR Document.
- Reporting can also make use of Questionnaires and Structured Data Capture for sending structured report data.
- Reporting may also use HL7 v2 or FHIR Messages for reports, see Observation Messages
Specifications
A number of NHS England API specifications can also be used to inform other practitioners of care provided. These are mostly focused on informing the patients general practitioner:
- GP Connect Send Document
- Transfer of Care Emergency Care Discharge - FHIR
- Transfer of Care Inpatient Discharge - FHIR
- Transfer of Care Mental Health Discharge - FHIR
- Transfer of Care Outpatient Clinic Letter - FHIR
- Digital Medicine - FHIR