MCC eCare Plan Draft Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions
Patient Story 1 Assumptions
Previous Page - MCC Use Cases
Patient
- Covered and eligible for all medical/social services described in the use case
- Capable of reading/comprehending at least at a high school level
- Able to access the EHR/PHR, the electronic care plan application, a smart phone, and email
- Able to grant consent to share data with selected Care Team members
Care Team Roles
- Primary Care Physician (PCP) and specialists document clinical/social care planning activities in the EHR
- Care Coordinator (triage nurse, social worker, discharge planning staff in inpatient units, community pharmacist) serves as care plan steward
- Reviews and reconciles care plan changes
- Reviews, manages, and monitors the action plan to address social needs
Technical Compliance
- EHR is able to capture/document and store medical and social data using standardized medical terminologies (For Example, LOINC, SNOMED-CT, ICD-10, CPT)
- EHR is able to connect and integrate with a SMART on FHIR App for care planning
- EHR can transmit or expose care coordination data (e.g. referral, consult, care summary, care plan) using FHIR-based specifications
- Care plan and EHR tie back to either 1) a single common database or 2) separate databases with common data elements and automated/near real-time integration
- Care plan has a revision history and subscription process
- Patient/Care Team are able to subscribe, define notifications, and designate recipients
- Subscribers can identify what revisions were made, who made them, and why
Data Sharing Practices
- Patient’s information is shared in compliance with privacy, security, and consent requirements
Care Plan Features
- Provides necessary access and entry authorization protocols for users
- Can identify and accommodate instances where different care team members access/edit the care plan at the same
Next Page - Patient Story
|
Propose a change