Patient Summary and Plan

Care Plan requires more specificity

Having a care plan is an appealing prospect, but the task of providing a care plan raises some fundamental questions. Does this mean a) the provider's text SOAP note, or does it mean b) structured data? If structured, does it mean c) a static set of information that has been signed by a provider, or d) anything planned, as in a 'dynamic' care plan that may change based on rules without the intervention of a central planner? If the latter, what rules define its scope?

Specifying the requirement without addressing these issues will usually result in the adoption of the lowest common denominator, (a), but less consistently than if specified.

CMS-CCSQ Support for Care Plan data class for USCDI v6

Data Elements: Care Plan Information, Assessment, Health Concerns, Goals, Interventions, and Outcomes/Evaluation

1. Recommendation: Add a Care Plan data class to Final USCDI v6.
2. Rationale: We continue to recommend a distinct Care Plan data class with a set of data elements (Care Plan Information, Assessment, Health Concerns, Goals, Interventions, and Outcomes/Evaluation). We define care plan as a shared dynamic longitudinal plan representing all care team members (including patient/caregiver) prioritized concerns, goals, interventions, and evaluation/outcomes across all health and social services settings. It can include a structured package of data elements that are already existing in USCDI. By adding Care Plan as a distinct class in the Final USCDI v6, it would encompass all data elements relevant to patient care planning. We believe Patient Summary and Plan are distinct concepts with patient summary component closely aligning to Clinical Notes data class. We propose repurposing the Patient Summary and Plan data class to the new Care Plan data class. Should this recommendation be adopted, we further recommend that the existing Assessment and Plan of Treatment (v5) data element, currently under the Patient Summary and Plan data class, be included in the new Care Plan data class. Including a Care Plan data class with relevant data elements will improve communication and care coordination across the care teams, improve patient safety and patient experience, and provide access to patient and caregiver-centric data.

NCQA Recommendations for USCDI v6- Care Plan

Care Plan

Recommendation type: Add new USCDI element.

Recommendation: Add Care Plan element to USCDI. 

Rationale: Care plans are able to be exchanged via FHIR (https://hl7.org/fhir/R4/careplan.html) and are critical components to high quality, person-centered care and care coordination. NCQA uses care plans in our person-centered outcomes measures to monitor and assess care aligned to the goals defined by the person. 

USCDI V5 Feedback

This Data Class should include a Patient Summary document which contains a summary of the patient’s relevant medical history.  This is the type of collection of information carried in a Continuity of Care Document (CCD) or an International Patient Summary (IPS) document. This Data Class needs to include: 

Patient Summary Document

A collection of information describing the patient’s medical history.

Care Plan Document

A collection of information describing a plan to direct the course of care for the patient.

Screenings and Screening Results

Questions and answers used to gather information from the patient to be used by a provider when assessing the patient, or measuring progress toward a goal.

Assessments 

A provider’s conclusions about a patient’s situation based on gathered information and physical observations of the patient’s condition.

Health Concerns

Issues identified by the patient or practitioner as having risen to the level of a “concern” to be tracked and addressed. The issues could be a medical problem identified on the patient’s Problem List, or it could any other type of issue that rises to the level of being a concern for the patient’s overall health.

Patient Goals

Patients goals, or goals for the patient set by provider or shared goals held by both the patient and provider, established as the desired outcome to guide the course of care.

Interventions or Plan of Treatment

A set of activities to be performed to achieve progress toward a patient goal.

Evaluations

Evaluations are similar to Assessments but for the timing and purpose. Assessments are made to determine diagnoses prior to developing a Plan.  Evaluations come after some or all of the interventions in a Plan have been performed and their purpose is to determine progress toward the goals which the plan is intended to meet. Because the diagnostic process is circular, Assessments and Evaluations appear to happen at the same point in the cycle. You have to look at the cycle as a linear process flattened out over time to see they are not the same thing. The work is similar in that there is a human clinician apply their professional judgement to the situation, but the purpose of the work differs.

Conclusions regarding progress toward a goal based on qualitative or observable or measurable information gathered by screening instruments, physical assessment, or other types of testing.

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Clarification Needed for Patient Summary and Plan

The Patient Summary and Plan data class needs to be renamed to Patient Assessment and Plan.

The Patient Summary and Plan data class should clarify that this data class covers Patient Assessment, and  Plan of Treatment information. Using the words “Patient Summary” is confusing because a “Patient Summary” is a type of Clinical Note Document that summarizes the patient’s medical history over a span of time. The term "Patient Summary" is widely used throughout the Sequoia, Commonwell/Carequality communities and will lead to widespread confusion if used here.

See related comments on how to clarify the Clinical Notes data class.

Lisa Nelson Comments 20230221_0.pdf