Patient Care Coordination (PCC) Implementation Guide - Local Development build (v0.1.1-current) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Official URL: https://fhir.virtually.healthcare/ImplementationGuide/fhir.virtually.healthcare				Version: 0.1.1-current
Draft as of 2025-11-05				Computable Name: VirtuallyHealthcare_IHEPCC

Patient Care Coordination (PCC)

How to Read this IG

	Menu Item	Description	Audience
	Analysis and Design (Volume 1)	Description of the processes and corresponding technical frameworks	General
	Interfaces (Volume 2)	Description of the processes and corresponding technical frameworks (HL7 v2 and FHIR Interactions)	Detailed Technical (Integration Developer)
	Domain Archetype (Volume 3)	Forms, Templates, Reports and Compositions	Data Modeling (Detailed Technical)
	Artefacts (Volume 4)	Common Data Models	Detailed Technical
	Development	Testing, Suppport and Architecture	Detailed Technical (Developer)

Clinical Process

The Patient Care Coordination (Community) is designed around supporting clinical processes in primary, pharmacy and community care settings. It is aligned with Nursing Process (ADPIE)

graph TD;
    Start --> |Perform Patient Administration| Assessment
    Assessment[Assessment]-->|Create Observations| Diagnosis;
    Assessment --> |"Shares Observations from Data Capture"| ClinicalDecisionSupport
    Assessment --> |Create Order| DiagnosticTesting

    ClinicalDecisionSupport[Clinical Decision Support]  --> |"Create Observation (Score)<br/>Cinical Assessment"| Diagnosis
    DiagnosticTesting[Diagnostic Testing] --> |"Sends Report <br/> Observations)"| Diagnosis
    Diagnosis[Diagnosis]-->|Create Condition| Plan;
    Plan -->|Creates Tasks| Implement;
    Implement[Implement/Interventions]-->|"Deliver Care <br/>(Series of Patient Encounters)"| Evaluate;
    Evaluate[Evaluate]-->Assessment;
    Evaluate --> |Perform Patient Administration| End

    EPR[fas:fa-database Electronic Patient Record] 
    Assessment --> |Read Care Record| EPR
    Diagnosis --> |Read Care Record| EPR
    Plan --> |Read Care Record <br/> Create Care Plan| EPR
    Implement --> |Read Care Record| EPR
    Evaluate --> |Read Care Record| EPR
    
    classDef yellow fill:#FFF2CC;
    classDef pink fill:#F8CECC
    classDef green fill:#D5E8D4;
    classDef blue fill:#DAE8FC;
    classDef orange fill:#FFE6CC;

    class Assessment pink
    class Diagnosis yellow
    class Plan green
    class Implement blue
    class Evaluate orange

Nursing Process (ADPIE)

Patient Care Process	Analysis and Design (Domain Driven Design)	Interfaces	Domain Archetype (Template and Composition)	Domain Entity (Resources)	Related NHS England
Start	IHE Patient Administration Management (PAM)	Event Notifications: HL7 v2 ADT IHE Patient Identity Management (ITI-30) HL7 v2 ADT IHE Patient Encounter Management (ITI-31) REST API: HL7 FHIR IHE Patient Demographics Query (PDQm)		Patient Encounter	REST API Personal Demographics Service
Assessment		​REST API: Device Data Capture HL7 FHIR Structured Data Capture Templates/Forms	Vital Signs Physical Activity Exercise Activity Social Context Smoking Status	Observation
- Clinical Decision Support	IHE Clinical Assessment (ACDC)			Observation Clinical Assessment
- Diagnostic Testing	IHE Laboratory and Testing Workflow (LTW) IHE Radiology (RAD)		HL7 Europe Laboratory Report HL7 Europe Imaging Report	ServiceRequest DiagnosticReport Observation	Pathology Messaging National Imaging Registry
Diagnosis				Condition
Plan	IHE Dynamic Care Planning (DCP)		Treatment Plan	Goal Care Plan
Implement				Task
- Order (Referral or Prescription)	IHE Patient Referral (360X) Medication Prescription and Dispense (MPD)		Referral Letter	ServiceRequest MedicationRequest	e-Referral Service Booking and Referral Standard Electronic Prescription Service
- Discharge Report/Consultation Note	IHE Patient Referral (360X)		Consultation Note HL7 Europe Hospital Discharge Report	Varies Resources	Transfer of Care
Evaluate			PROMS?
Electronic Patient Record	Health Information Exchange HIE	REST API: HL7 FHIR IHE Query for Existing Data QEDm PCC-44 IHE Health Documents MHD ITI-67	Patient Care Record	Varies Resources
End	IHE Patient Administration Management (PAM)	Event Notifications: HL7 v2 ADT IHE Patient Encounter Management (ITI-31)		Encounter

Patient Encounters

Patient Encounters occur multiple times throughout a patient’s care journey and may be repeated at various stages. The diagram below illustrates that each encounter involves several steps — it’s a flexible, iterative process. To make this clearer for both developers and non-clinical users, the SOAP Notes framework has been used as a reference.

While this description reflects a physician-centered workflow, the clinical process is more closely aligned with nursing practices.

The data archetype associated with this is Consultation Note

Event notifications are common in secondary care, where they are known as HL7 v2 Admission, Discharge and Transfer (ADT) and also IHE Patient Administration Management (PAM) - Patient Encounter. Note that HL7 FHIR does not currently define a specific standard for these event notifications. Some general practice (GP) systems do, however, receive such encounter notifications from secondary care.

graph TD;
    Start[Start] --> Subjective
    Subjective --> Objective 
    Objective --> Assessment 
    Assessment[Assessment / Differential Diagnosis] --> Plan 
    Plan --> End
    Subjective --> |View Patient Record| HIE[fas:fa-database Clinical Portal /<br/> Electronic Patient Record /<br/> Health Information Exchange] 
    End --> |Encounter Notification| Other["Other Practitioners and <br/>Patient (if not present)"]
    Subjective --> |Query Patient| Patient
    Objective --> Patient 

    Subjective --> |Create Observations| EPR[fas:fa-database Electronic Patient Record] 
    Objective --> |Create Observations| EPR[fas:fa-database Electronic Patient Record] 
    Assessment --> |Create Condition| EPR[fas:fa-database Electronic Patient Record] 
    Plan --> |Create Tasks| EPR[fas:fa-database Electronic Patient Record] 
    Plan --> |"Create Prescriptions and Orders (Referrals and Diagnostic)"| Other

    classDef yellow fill:#FFF2CC;
    classDef pink fill:#F8CECC
    classDef green fill:#D5E8D4;
    classDef blue fill:#DAE8FC;
    classDef orange fill:#FFE6CC;

    class Subjective pink
    class Objective pink
    class Assessment yellow
    class Plan green

Patient Encounter Process	Analysis and Design (Domain Driven Design)	Interfaces	Domain Archetype (Template and Composition)	Domain Entity (Resources)	Related NHS England
Subjective	Uses Health Information Exchange (HIE)		Views Patient Care	Creates Observation
Objective			May use templates to capture data, see assessment in clinical-process	Creates Observation
Assessment				Creates Condition
Plan			Referral Letter	ServiceRequest MedicationRequest Task	See Order from clinical-process

Technical Overview

High Level Architecture

The diagram below shows the high level architecture of the Patient Care Coordination Manager (Community)

Patient Care Coordination Manager (Community)

This uses a series of common data and interaction standards (green in the diagram below) which allow different applications to be connected together. These interfaces will often provide a layer of extraction of over other interfaces such as:

• ​Consultation Note
  • GP Connect Send Document
  • NHS England Digital Medicines
  • NHS England IM1 Transaction API
• ​Referral Letter
  • NHS England Booking and Referral Standard (BARS)
  • NHS England Electroninc Referral System (eRS)
• Patient Clinical Data Sharing
  • GP Connect Access Record: HTML
  • GP Connect Access Record: Structured
  • GP Connect Access Record: Document
  • NHS England IM1 Transaction API
• Care and Patient Directory
  • NHS England Personnel Demographic Service (PDS)
  • Directory of Service (DoS)
  • Organisation Data Service
  • Spine Directory Service

Enterprise Frameworks

A number of frameworks IHE Patient Care Coordination (PCC) are followed in this guide, including:

• Query for Existing Data for Mobile (QEDm)
• Dynamic Care Planning (DCP)
• Mobile access to Health Documents (MHD) (A REST API for IHE XDS.b and EDMS)
• Mobile Care Services Discovery (mCSD)
• Patient Demographics Query for Mobile (PDQm)

Technical Workflow

The interactions use HL7 FHIR and is designed to be compatible with:

• HL7 v2 Messaging via:
  • FHIR Messaging - a direct conversion of HL7 v2 Messaging
  • HL7 FHIR Workflow which allows Conversation Patterns
  • HL7 FHIR Subscription
• HL7 Clinical Document Architecture via:
  • FHIR Documents

Data Standards

Support for these frameworks includes core canonical data model/domain model which meets general NHS requirements:

• UK SNOMED CT for our clinical terminology.
• NHS Data Dictionary for identifiers and values, such as NHS Number, GMC, GMP, ODS, etc.
• HL7 UK Core.

SNOMED CT

UK edition of SNOMED (83821000000107)

Dependencies

Package hl7.fhir.uv.extensions.r4#5.2.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Mon, Feb 10, 2025 21:45+1100+11:00)

Package fhir.r4.ukcore.stu3.currentbuild#0.0.19-pre-release UK Core FHIR profiles and Assets

Package hl7.fhir.uv.sdc#3.0.0 The SDC specification provides an infrastructure to standardize the capture and expanded use of patient-level data collected within an EHR. This includes two components: * Support more sophisticated questionnaire/form use-cases such as those needed for research, oncology, pathology and other clinical domains. *Support pre-population and auto-population of EHR data into forms/questionnaires for uses outside direct clinical care (patient safety, adverse event reporting, public health reporting, etc.). (built Tue, Mar 8, 2022 18:32+0000+00:00)

Package hl7.fhir.uv.ipa#1.0.0 This IG describes how an application acting on behalf of a patient can access information about the patient from an clinical records system using a FHIR based API. The clinical records system may be supporting a clinical care provider (e.g. a hospital, or a general practitioner), or a health data exchange, including a national health record system. (built Sun, Mar 26, 2023 20:50+0000+00:00)

Package hl7.fhir.uv.tools.r4#0.8.0 This IG defines the extensions that the tools use internally. Some of these extensions are content that are being evaluated for elevation into the main spec, and others are tooling concerns (built Tue, Aug 5, 2025 20:09+1000+10:00)

Credits

Role(s)	Contributor(s)
	Virtually Healthcare
Enterprise Architect	Kevin Mayfield (Mayfield IS)