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What the Solution Looks Like (Future State)

Overview of 5-year Destination 

Communication: Data Exchange with Unambiguous Definitions

  • Data are accessible in real time at any time by anyone with authorized access
  • Data are interoperable across different systems and organizations

Care Planning

  • Supports collaborative care plan development and implementation by the entire care team (including the patient, all clinicians, and caregivers)
  • Supports a care model that increases preventive services and provides problem-based support within and outside of traditional office encounters (including telehealth, conversational AI, and services beyond legacy clinical services to include the spectrum of SDoH services such as food security, transportation, etc.)
  • Care plans reflect a shared-decision making process that is driven by all the patient's health and social data (gathered automatically), and informed by all pertinent evidence for the patient's health issues (e.g., preventive care and for managing common and important acute and chronic clinical issues) as well as the person's individual health and social needs, goals, preferences and priorities. 
  • Reconciles the combined set of problem-focused care plans into a unified/integrated care plan that provides a coherent and feasible evidence-informed set of actions and, ultimately, has development and implementation enhanced by AI and machine learning (ML) approaches and tools
  • Evolves the patient’s care plan as circumstances change based on input from the patient and the care team, data from information systems, and updated evidence and recommendations (which are automatically delivered to care plan templates and patient-specific care plans)

 Care Coordination

  • Coordinates user input and activities across the care team (i.e., patient, caregiver, primary care providers, specialists, facilities, and organizations
  • Supports the common situation where patients have multiple chronic conditions

Knowledge Supplementation

  • Provide knowledge at the right time for the right issue in a user-friendly way, e.g., via patient and provider-focused knowledge resources and CDS interventions linked to the CSCP, and tools to support shared decision making driven by CSCP data.

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image above from Stephen Chu, HL7 Patient Care WG  (from these slides)