Value-Based Care Management system - sample functional specs

  A Value-Based Care Management system is complex, aiming to shift from fee-for-service to an outcome-driven model. Here are the functional specifications broken down by the components you've listed:

Functional Specifications for Value-Based Care Management System

I. Patient Attribution & Segmentation

A. Functional Requirements:

1. Data Ingestion & Integration:

   • The system shall integrate with various data sources (EHR/EMR, claims data, pharmacy data, lab results, patient-reported data, social determinants of health data, wearable device data) to acquire comprehensive patient information.

   • It shall support real-time and batch data ingestion from disparate systems.

   • It shall perform data normalization, cleansing, and de-duplication to ensure data quality.

2. Attribution Logic Engine:

   • The system shall implement configurable rules and algorithms for patient attribution (e.g., primary care physician relationship, majority of claims, geographic proximity, payer assignment).

   • It shall allow for multiple attribution methodologies to be run concurrently or sequentially.

   • It shall support manual override and approval processes for attribution decisions.

3. Patient Segmentation Engine:

   • The system shall utilize machine learning (ML) algorithms (e.g., clustering, predictive analytics) to stratify patients into risk categories (e.g., low, moderate, high risk) based on clinical, demographic, and historical data.

   • It shall identify patients with specific chronic conditions (e.g., diabetes, heart failure, COPD) or complex care needs.

   • It shall enable custom segmentation criteria based on user-defined rules and business needs (e.g., socio-economic factors, adherence to medications).

   • It shall automatically assign segmented patients to appropriate care programs.

4. Patient Profile Management:

   • The system shall generate a comprehensive 360-degree view of each patient, including demographics, medical history, medications, allergies, social determinants of health, risk scores, and care program assignments.

   • It shall allow authorized users to view and update patient profiles.

5. Reporting & Analytics:

   • The system shall generate reports on patient attribution statistics (e.g., number of attributed patients per provider, per program).

   • It shall provide insights into patient segment distribution and demographic breakdowns.

B. Non-Functional Requirements:

• Scalability: Ability to handle a large and growing patient population.

• Performance: Efficient processing of large datasets for attribution and segmentation.

• Security & Privacy: Adherence to HIPAA, GDPR, and other relevant data privacy regulations. Robust access controls.

II. Assignment to Care Programs

A. Functional Requirements:

1. Care Program Repository:

   • The system shall maintain a centralized repository of defined care programs, including their goals, target patient populations, intervention strategies, and associated resources.

   • It shall allow for creation, editing, and deactivation of care programs.

2. Automated Assignment Rules:

   • The system shall automatically assign segmented patients to the most appropriate care programs based on their risk profile, chronic conditions, and other relevant criteria.

   • It shall allow for the definition of rule-based assignments (e.g., "all diabetics with high A1c go to Diabetes Management Program").

3. Manual Assignment & Override:

   • The system shall allow care managers or clinical staff to manually assign patients to care programs or override automated assignments.

   • It shall track reasons for manual assignments/overrides.

4. Capacity Management:

   • The system shall ideally consider the capacity of care teams and programs when assigning patients to prevent overload.

5. Notification & Workflow:

   • The system shall notify relevant care team members upon a patient's assignment to a program.

   • It shall trigger initial workflows associated with program enrollment (e.g., initial assessment tasks).

B. Non-Functional Requirements:

• Auditability: Track all changes and assignments to care programs.

• Usability: Intuitive interface for managing care programs and assignments.

III. Care Plan Definition Liaising with Clinical Teams

A. Functional Requirements:

1. Collaborative Care Plan Creation:

   • The system shall provide a collaborative platform for clinical teams (physicians, nurses, social workers, pharmacists) to define and customize care plans for individual patients or patient segments.

   • It shall support the use of standardized care plan templates based on best practices and clinical guidelines.

   • It shall allow for the creation of condition-specific care plans (e.g., congestive heart failure, diabetes).

2. Goal Setting & Measurement Integration:

   • The system shall facilitate the definition of both short-term and long-term care goals, including measurable targets (e.g., reduce HbA1c to <7%, increase activity level by X steps/day).

   • It shall link care goals to specific clinical quality measures.

3. Intervention & Task Management:

   • The system shall allow for the definition of specific interventions, tasks, and activities within the care plan (e.g., medication adherence checks, dietary counseling, physical therapy referrals, follow-up appointments).

   • It shall support assigning tasks to specific care team members with due dates and priorities.

4. Patient Engagement Features:

   • The system shall support patient-facing elements of the care plan, allowing patients to view their goals, tasks, educational materials, and progress.

   • It shall facilitate secure communication between patients and their care team (e.g., secure messaging).

5. Version Control & Audit Trail:

   • The system shall maintain version control for care plans, tracking all modifications and the users who made them.

   • It shall provide an audit trail for compliance purposes.

6. Knowledge Base Integration:

   • The system shall integrate with clinical knowledge bases and evidence-based guidelines to support care plan development.

B. Non-Functional Requirements:

• Interoperability: Ability to exchange care plan data with EHR/EMR systems.

• Security: Ensure confidentiality of patient data within the collaborative environment.

IV. Define Care Goals

A. Functional Requirements:

1. SMART Goal Definition:

   • The system shall guide users in defining SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) for patients.

   • It shall provide templates and examples for common care goals.

2. Progress Tracking against Goals:

   • The system shall enable tracking of patient progress against defined goals using various data inputs (e.g., lab results, vital signs, patient-reported outcomes, survey data).

   • It shall provide visual dashboards to display goal attainment and trends.

3. Alerts & Notifications:

   • The system shall generate alerts and notifications when patients are not progressing towards their goals or when a goal milestone is approaching.

4. Goal Revision & Archiving:

   • The system shall allow for revision of care goals as patient conditions change or as goals are achieved.

   • It shall support archiving completed or outdated goals.

B. Non-Functional Requirements:

• Real-time Updates: Ability to reflect real-time changes in patient data impacting goal progress.

• Configurability: Ability to customize goal types and tracking metrics.

V. Clinical Quality Measures

A. Functional Requirements:

1. Measure Repository & Management:

   • The system shall maintain a repository of standard clinical quality measures (CQMs) (e.g., HEDIS, meaningful use measures, MIPS/MACRA measures).

   • It shall allow for the definition of custom organizational-specific quality measures.

   • It shall support versioning and updates of measures.

2. Automated Data Extraction & Calculation:

   • The system shall automatically extract relevant data from integrated sources (EHR, claims, lab) to calculate CQMs.

   • It shall handle complex logic for measure calculation, including exclusions and exceptions.

3. Performance Dashboards & Reporting:

   • The system shall provide interactive dashboards to visualize performance against CQMs at various levels (individual patient, provider, care team, program, organization).

   • It shall generate auditable reports for regulatory compliance and internal review.

4. Drill-down Capabilities:

   • Users shall be able to drill down from aggregate measure performance to individual patient data to understand the underlying factors.

5. Gap Identification & Intervention Prioritization:

   • The system shall identify gaps in care based on CQM performance (e.g., patients overdue for screenings, uncontrolled chronic conditions).

   • It shall highlight patients who are negatively impacting overall measure performance, enabling targeted interventions.

6. Benchmarking:

   • The system shall support benchmarking against industry standards, peer groups, or historical performance.

B. Non-Functional Requirements:

• Accuracy: High accuracy in measure calculation.

• Performance: Efficient calculation of measures across large datasets.

• Regulatory Compliance: Adherence to all relevant reporting standards.

VI. Build Care Coordination Journeys

A. Functional Requirements:

1. Workflow Engine & Automation:

   • The system shall provide a configurable workflow engine to define and automate multi-step care coordination journeys (e.g., post-discharge follow-up, chronic disease management pathway).

   • It shall support rule-based triggering of workflows (e.g., "on patient discharge, initiate post-discharge follow-up workflow").

2. Task Management & Assignment:

   • The system shall automatically generate and assign tasks to appropriate care team members based on the defined journey steps.

   • It shall support manual task creation and reassignment.

   • It shall allow for task prioritization and due dates.

3. Communication & Collaboration Tools:

   • The system shall provide secure communication channels for care team members (e.g., in-system messaging, secure email integration).

   • It shall support shared notes, alerts, and notifications within the care team.

   • It shall integrate with patient communication tools (e.g., patient portal, secure messaging).

4. Referral Management:

   • The system shall facilitate seamless internal and external referrals, tracking referral status and outcomes.

   • It shall integrate with provider directories.

5. Appointment Scheduling & Reminders:

   • The system shall support scheduling of appointments (internal and external) and send automated reminders to patients and providers.

6. Progress Monitoring & Escalation:

   • The system shall allow care team leads to monitor the progress of patients through their care journeys.

   • It shall trigger escalation protocols for tasks that are overdue or when critical events occur.

7. Documentation & Audit Trail:

   • The system shall meticulously document all interactions, decisions, and outcomes within the care coordination journey.

   • It shall provide a comprehensive audit trail for every action.

8. Patient and Family Engagement:

   • The system shall support features to keep patients and their families informed about their care journey steps and progress.

   • It shall provide access to educational materials relevant to their journey.

B. Non-Functional Requirements:

• Flexibility: Ability to adapt to changing care models and clinical guidelines.

• Integration: Seamless integration with existing clinical and administrative systems.

• User Experience: Intuitive and efficient for care managers and clinical staff.