CSIRO (Case Study 3)

FHIRing up team care arrangements with SNOMED CT- Supporting team care arrangements for people living with chronic conditions through the use of a FHIR and SNOMED CT enabled chronic condition management plan.

APAC

Clinical Practice, Collaboration, Data quality, Implementation, Tooling

Approximately 6 out of every 10 of Australians have more than one chronic condition at any one time. The Australian Institute of Health and Welfare (AIHW) indicate there are twelve main conditions that make up chronic conditions (these being:Arthritis, Asthma, back problems, Cancer, Cardiovascular disease, chronic obstructive pulmonary disease, dementia, diabetes, chronic kidney disease, endometriosis, mental health and osteoporosis)[2]. Evidence has shown that patients and care team members favour the multidisciplinary approach to chronic condition management, due to the overlapping nature of symptoms and the high degree of burden conditions have on quality of life.

Sparked, Australia's FHIR Accelerator is developing through an open collaborative process the foundation specifications to support team care arrangements through the development of:

* Expansion of AU Clinical Data For interoperability ( AUCDI)to include data groups and data elements to support chronic condition management,
* Identification of the appropriate SNOMED CT value sets
* Development of a SMART FORM , based on FHIR Questionnaire which can support a collaborative team care arrangements.

Description

Sparked, Australia's FHIR Accelerator has over 1000 members representing government, clinicians, industry and consumers. Sparked over the last two years has delivered the initial release of AUCDI, AU CORE FHIR IG, AU eRequest IGs and the associated SNOMED CT Value Sets.

The latest release of AUCDI provides data groups to help support care planning and chronic condition management. AUCDI Release 2 CCM contains new data groups and data elements that were identified by the Sparked CDG as important for inclusion as a first step towards standardising data to support and enable information capture, exchange, and meaningful use across an individual's health care and care team for chronic condition management. workshops were held throughout the second half of 2024, where teams of clinicians, informaticians, patient advocate representatives, government representatives and technicians gathered in workshops across the country to help focus on the necessary data group requirements to support chronic care

Further enhancements to the data groups and elements will come as the scope and breadth of data requirements for chronic condition management are developed.

A Clinical Focus Group has been established to document the use cases and data flows that underpin team care arrangements to inform the development of a Team Care, Chronic Condition Management Plan based on FHIR Questionnaire. Through this process we will identify the elements of the management plans, which can now be structured and coded- which normally would be free text.This project will also identify gaps in SNOMED CT content.

Through the use of SNOMED CT within these structured care plans, we will enable better integration of electronic clinical decision support, support reuse of the data for service requests and support use of the data for clinical quality measure and quality indicator reporting.

Scope

SNOMED CT is Australia's preferred clinical terminology and is the clinical terminology of choice in the national standards (Australian Clinical Data For Interoperability (AUCDI) and AU Core FHIR Implementation guide. SNOMED is chosen to not only support the exchange of information , but we also recommend its use as the interface terminology within the record. The use of FHIR Questionnaires supports the pre pop of coded data and also postpopulation back within the clinical record- enhancing clinical workflow and utility of the data.

We also want to support advanced workflow with SNOMED CT supporting integration of decision support for recommended care pathways and advanced data analytics for quality measures.

How SNOMED CT will be used

SNOMED CT is use as the clinical terminology of choice for data entry within electronic medical records, for exchange and for data analytics. SNOMED CT value sets are defined as part of AUCDI and included in our national FHIR Implementation Guides. We work with the Clinical Colleges and Software Industry to validate the inclusion of SNOMED CT as the preferred terminology and identify processes to address any content gaps.