Care Plans

Provision of Clinical Recommendations to Patients and Providers Regarding Individualized Care Plans

Scenario Details: David’s next patient in clinic is Terry, an obese patient almost 140 lbs overweight. Terry needs an individualized and medically responsible program to safely lose weight, so David uses a special tool to design a plan specifically for Terry. He establishes a timeline for the plan, measurement intervals for when actual progress should be compared to the idealized “glide path”, and thresholds above or below which additional recommendations on how to intervene will be provided. These additional evaluations are based on custom rules particular to David’s practice style that the editor enables David to capture. Terry is then provided with a special scale that will transmit daily weights back to the DSS system for evaluation.

Over the course of the next 15 weeks, Terry does well, losing weight at an appropriate rate. Over the Thanksgiving and Christmas holidays, however, he over indulges, and his 7-day moving average exceeds plan thresholds. The DSS system notifies David that Terry is no longer meeting his targets and places orders of a weight loss support group and an observed exercise program. When David provides his electronic signature, the system emails Terry, notifies him of the new recommendations, provides literature references to support their utility, and makes the schedules for the support group and exercise class available to him so he can book the appointments himself online.

After a few stops and starts where Terry cancels and reschedules his appointments, he resumes losing weight and eventually meets his target only four weeks over due.

Actors: Patient (Terry), Physician (David)

Requirements:

Requirement #	Description
1.2.1	The System shall have access to relevant patient medical data including diagnoses, medications, adverse events, radiology, labs, appointments, etc.
1.2.2	The System shall expose notification mechanisms (voicemail, pager, email, etc) for use in creating knowledge modules.
1.2.3	The System shall enable providers to create, edit and store individual patient rules and workflows
1.2.4	The System shall provide (signal-processing) tools to automatically clean up noisy data such as self-reported medical device data delivered from non-institutional sources (e.g.: home). Clean up could include elimination of clear outliers.
1.2.5	The System shall enable providers to receive (optionally after automatic clean-up), edit and submit for final storage medical data delivered from non-institutional sources (e.g. home devices such as a scale or glucometer)
1.2.6	The System shall be capable of automatically executing individual patient rules and workflows on data received from non-institutional sources before physician review (event warning).
1.2.7	The System shall be capable of automatically executing individual patient rules and workflows on data received from non-institutional sources only after physician review (definitive warning).
1.2.8	To further generalize Requirements 1.2.6 and 1.2.7 above, the System shall provide a flexible and configurable workflow routing function. Example: direct to patient without provider review/approval, or only after provider review/approval, etc.
1.2.9	The System shall provide a secure capability for patient–provider email communication
1.2.10	The System shall provide patients with a self-appointing capability where they can book, cancel, and reschedule appointments.
1.2.11	The System shall provide justifications and references to be optionally returned with CDS recommendations for inclusion within notifications to recipients.