Care Plan (CP) Team Meeting Notes(As updated during meeting)
André Boudreau ([email protected])
Laura Heermann Langford ([email protected])
2011-04-20 (No. 10)
HL7 Patient Care Work Group
Page 2
Agenda for April 20
• Preparation for WGM in Orlando• Care Plan elements from KP, Intermountain, etc. (Laura)• Feedback on models prepared by Stephen (Laura and Susan)• Updated doc on storyboards (Danny)• IHE Patient Plan of Care (PCCP) (Ian M.): deferred• Modeling tool to use (Eclipse or EA) (André)• Overarching term to use (Ian M.) deferred• Business requirements: summary of key aspects since
February (André) deferred This will become eventually our first formal deliverable
• Next meeting agenda
Page 3
Agenda for April 27
• Summary of care plan situations (Susan)• Feedback and discussion on first storyboard: Chronic
Care (Danny to circulate in advance)• Highlights from IHE Patient Centered Coordination
Plan (PCCP) (Ian M.)• Coaching on Eclipse: what to install for our needs,
quick start (Kevin)
Page 4
Participants- Meetg of 2011-04-20 p1Name email Country Yes Notes
André Boudreau [email protected] CA Yes Co-Lead- Care Plan initiative/HL7 Patient Care WG. B.Sc.(Physics), MBA. Owner Boroan Inc. Management Consultin. Chair, Individual Care pan Canadian Standards Collaborative Working Group (SCWG). Sr project manager. HL7 EHR WG.
Laura Heermann Langford [email protected] US Yes Co-Lead- Care Plan initiative/HL7 Patient Care WG. Intermountain Healthcare. RN PhD,: Nursing
Informatics; Emergency Informatics Association, American Medical Informatics Association; IHE
Stephen Chu [email protected] AU Yes NEHTA-National eHealth Transition Authority . RN, MD, Clinical Informatics; Clinical lead and Lead Clinical Information Architecture; co-chair HL7 Patient care WG; vice-chair HL7 NZ
Peter MacIsaac [email protected] AU HP Enterprise Services. MD; Clinical Informatics Consultant; IHE Australia; Medical Practitioner - General Practice
Adel Ghlamallah [email protected] CA Canada Health Infoway. SME at Infoway (shared health record); past architect on EMR projects
William Goossen [email protected] NL Results 4 Care B.V. RN, PhD; -chair HL7 Patient Care WG at HL7; Detailed Clinical Models ISO TC 215 WG1 and HL7 ; nursing practicioner
Anneke Goossen [email protected] NL Results 4 Care B.V. RN; Consultant; Co-Chair Technical Committee EHR at HL7 Netherlands; Member at IMIA NI; Member of the Patient Care Working Group at HL7 International
Ian Townsend [email protected] UK NHS Connecting for Health. Health Informatics; Senior Interoperability Developer, Data Standards and Products; HL7 Patient Care Co-Chair
Rosemary Kennedy [email protected] US Thomas Jefferson University School of Nursing . RN; Informatics; Associate Professor; HL7 EHR WG; HL7 Patient care WG; terminology engine for Plan of care;
Jay Lyle [email protected] US JP Systems. Informatics Consultant; Business Consultant & Sr. Project Manager
Margaret Dittloff [email protected] US Yes The CBORD Group, Inc.. RD (Registered Dietitian); Product Manager, Nutrition Service Suite; HL7 DAM project for diet/nutrition orders; American Dietetic Association
Audrey Dickerson [email protected] US HIMSS. RN, MS; Standards Initiatives at HIMSS; ISO/TC 215 Health Informatics, Secretary; US TAG for ISO/TC 215 Health Informatics, Administrator; Co-Chair of Nursing Sub-committee to IHE-Patient Care Coordination Domain.
Ian McNicoll [email protected] UK Yes Ocean Informatics . Health informatics specialist; Formal general medical practitioner; OpenEHR; Slovakia Pediatrics EMR; Sweden distributed care approach
Danny Probst [email protected] US Yes Intermountain Healthcare. Data Manager
Kevin Coonan [email protected] US Yes MD. Emergency medicine. HL7 Emergency care WG.
Gordon Raup [email protected] US CTO, Datuit LLC (software industry).
Susan Campbell [email protected] US Yes PhD microbiologist. Specialist Master Consultant at Deloitte. HL7 Dynamic Care Plan Co-developer
Elayne Ayres [email protected] US NIH National Institutes of Health. MS, RD; Deputy Chief, Laboratory for Informatics Development, NIH Clinical Center ; Project manager for BTRIS (Biomedical Translational Research Information System), a Clinical Research Data Repository
Page 5
Participants- Meetg of 2011-04-20 p2Name email Country Yes No Notes
David Rowed [email protected] AUCharlie Bishop [email protected] UKWalter Suarez [email protected] US YesPeter Hendler [email protected] USRay Simkus [email protected] CALloyd Mackenzie [email protected] CA LM&A Consulting Ltd.Serafina Versaggi [email protected] US Yes
Sasha Bojicic [email protected] CA Lead architect, Blueprint 2015, Canada Health Infoway
Agnes Wong [email protected] CA
RN, BScN, MN, CHE. Clinical Adoption - Director, Professional Practice & Clinical Informatics, Canada Health Infoway
Cindy Hollister [email protected] CARN, BHSc(N), Clinical Adoption -Clinical Leader, Canada Health Infoway
Valerie Leung [email protected] CA Pharmacist. Clinical Leader, Canada Health Infoway
Page 6
Preparation for WGM in Orlando in May
• Try to have conf call facility during our Care Plan session to allow participation of those who will not be on site Lillian Bigham, director of meetings is responsible for logistics Stephen will contact her with that
• Scheduled for Thursday Q1: 9-11h30 (time in AU will be 23h00 to 00h30)
• Try swapping with another period? NO. Stephen to double check.
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Care Plan Elements from KP, VA, Intermountain, Mayo, etc.
• Request was sent out by Laura Some initial feedback, better to wait next week Working with these organizations. Still in process.
• What are they using today in terms of contents• Try collecting policies and rules especially on the
interchange of clinical info related to care plans• Different models are used for different contexts:
simple coordination to catastrophic intervention (whole range of levels from non licensed person to catastrophic case with multi dimensional coverage) Susan could prepare matrix or summary Will enrich our statement of requirements
Page 9
Process Models
• Models are generating a lot of discussions in the US. Not discussed at this level in the past.
• Linking of components is not clear, how to connect detailed plans to the master?
• Patient may/should (?) be the coordinator with exceptions Make the patient owner of the CP We are not there yet, but it is a trend Patient has the last say in many actions (comply or not comply) PHR are rudimentary yet, no standards to interoperate PHR does not equal care coordination
• We need to assume a coordinator, whomever he/she is Most countries have not had that concept in place, formally
• Dynamism: a key concept because things happen and move• Transition on care (S&I): handoff required, need to prevent void of
care• CP are complex. Aim at better outcomes from our care• Multi level dynamic care planning requires tool that may not exist• See: www.healthycircles.com www.patientsknowbest.com
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Process Models cont’d
• We need to scope out what kind of care plan we want to deal with• What are the priority cases?
Take complex cases that are very costly Look at whole series of processes: prep, coordinate, update, assess, close Understanding the whole process to ensure that we capture the correct
data in the interchange There is a ramp up before the transition of care to ensure patient safety:
patient preparation, search for availability of resources for the patient care needs, awareness and readiness of receiving of organization
• High volume cases: simple model• Simple or complex cases have the same contents
Detailed clinical contents will vary Wrapper of care plan communication
• Stephen will look at the range of situations that Susan will document• We will need to restrict ourselves to the Care Plan: structure and
contents in the information exchange
Page 11
Care Plan – High Level Processes
Stephen Chu12 April 2011
Identify problems/issues/reasons
Assess impact/severity: referral order tests
Initial Assessment
Confirm/finalize problem/concern/reason list
Determine goals/intended outcomes
Determine Problems & Outcomes
Set outcome target date
Implement interventions
Care Plan Implementation
Evaluate patient outcome
Review interventions
Evaluation
Document outcomes
Revise/modify interventions
OR
Close problem/issues/reason/care plan
Follow-up Actions
Goals/Outcomes:- Optimize function - prevent/treat symptoms - improve functional capability - improve quality of life- Prevent deterioration - prevent exacerbation; and/or - prevent complications- Manage acute exacerbations- Support self management/care
Care Plan
Care orchestration
Problem/concern/reason 1..* Target goals/outcomes Planned intervention Assessed outcome
High Level Shared Plan
Detailed Care PlanDetermine/plan appropriate interventions
Determine/assign resources healthcare providers other resources
Develop Plan of Care
Refer to other provider (s)
Care orchestration
April 13
IHE has more loose connections. Here assumes workflow engine that connects tightly problem, goal, task.Need distinct process to manage/communicate/update/track/close the Care Plan. See IHE. Make more explicit here.
This is illustrative
Need to study this more:Laura and Susan to work on it
Page 12
Care Plan – Process-based Structure
Stephen Chu12 April 2011
Identify problems/issues/reasons
Assess impact/severity: referral order tests
Initial Assessment
Confirm/finalize problem/concern/reason list
Determine goals/intended outcomes
Determine Problems & Outcomes
Set outcome target date
Implement interventions
Care Plan Implementation
Evaluate patient outcome
Review interventions
Evaluation
Document outcomes
Revise/modify interventions
OR
Close problem/issues/reason/care plan
Follow-up Actions
Goals/Outcomes:- Optimize function - prevent/treat symptoms - improve functional capability - improve quality of life- Prevent deterioration - prevent exacerbation and/or - prevent complications- Manage acute exacerbations- Support self management/care
Care Plan
Problem/issue/risk/reason Desired goal/outcome Outcome target date
Planned intervention/care service Planned intervention datetime/time interval (including referrals) links to other care plan as service plan Responsible healthcare & other provider(s)
Intervention review datetimeResponsible review party/parties
Review outcome
Review recommendation/decision
Care orchestration
Determine/plan appropriate interventions
Determine/assign resources healthcare providers other resources
Develop Plan of Care
Refer to other provider (s)
Problem/concern/reason 1..* Target goals/outcomes Planned intervention Assessed outcome
High Level Shared Plan
Care orchestration
Will need to add explanations and maybe some different scenarios
Page 14
Storyboard: what is it?
• Narrative of business (clinical; administrative) processes on domain/area of interest
• Non technical (conceptual in nature)• Describes:
• Activities, interactions, workflows• Participants• High level data contents feeding into or resulting from
processes• Provides inputs for:
• Activity diagrams• Interaction diagrams• State transition diagrams• High level class diagrams
Stephen Chu12 April 2011
Page 15
Storyboards
• 5 to 10 max See list on wiki
• Identify actors and understand their roles• Understanding the care planning processes will help
understand the needs for info exchange E.g. query for resource availability vs the care plan needs for
patient X• 3 types of requirements
Functions to be carried out, workflow, processes Static semantics: info model, glossary, vocabulary Functions to be carried out by the system: EHR FM, PHR FM, etc Interactions between systems: interoperability
• Include meaningful use items that are universal in perspective
Page 17
Modeling Tool to Use• Responses from Lloyd Mackenzie and Jean Duteau
Both use Enterprise Architect (EA)• Response from Andy Stechishin, HL7 Tooling and V3 Publishing co-chair
First, there is an active Tooling project (called MAX) to export information from EA using MIF, the HL7 official interchange format.
Second, at the WGM in Sydney, Sparx gave each attendee a license for EA. Third, during my tenure as a co-chair of Publishing, most DAMs that have been submitted for ballot
have been developed (or at least published) using EA. It seems to me that a convergence is occurring and EA seems to at least be the tool of choice for
many.• Eclipse is a platform for doing many different things using specific plug-ins
Recommended by HL7 Open Source but not as intuitive as Enterprise Architect (which costs some 100$ for a desktop
version) However, choosing which tool and plug-in (for UML) to install is difficult for non technical folks (vs
the easy-to-use EA) We would need some coaching to allow a quick start
o Adel agreed to help us thereo André will find a resource
• The tool will be used to do: Use cases Activity and workflow diagrams Interaction diagrams Class models
Includes post-meeting notes
Page 19
Issues
• What overarching term to use? Condition: favoured by Care Provision: more neutral than ‘concern’ Concern: allows for broader set of contexts for care planning, including
health maintenance activities Problem: focus on ‘wrong’ things; not well applicable to pregnancy: NO Health status: ‘current’ is not a term used Health issue: many people use it. Europe uses it (e.g. Sweden) See terms proposed (Susan) Synonyms: issue, concern We need to choose, define it and map it to existing terms Wait for our storyboards and map the correct word to each Build on existing term work done by reliable sources: HL7 Care Provision,
ISO/CEN concepts (Continuity of Care) Existing glossaries: HL7, CCMC (case management assoc), NLM Retain meaning of natural language where possible Use reliable sources Ian: he has done a term analysis
• Note: None of these terms are in the HL7 Core Glossary. See http://www.hl7.org/v3ballot/html/welcome/environment/index.html
Page 20
‘Condition’ vs ‘Problem’: From Care Provision (Jan 2011)• …the term “Condition” is used generally in HL7 because it is less
negative than “problem,” i.e. management of normal pregnancy or wellness is not considered management of a “problem.” In addition, assessing and optimizing the condition of a patient is considered central to effective healthcare by clinicians. Much of the following is shared by the generalized discussions under Condition List and Condition Tracking. Additional guidance on the use of the Condition List and Condition Tracking structures in the specific use cases of allergy and intolerance is given following the general discussions below.
Source: ExplanationandGuidance.pdf document in the Care provision package v3_careprovision_2011JAN.zip
Page 21
Health concern and care plan: new paradigm to define the EHRS• Historically, the EHR was similar to the GHR (Guttenberg Health
Record) that was systematically adhered to as it had since Sir. William Osler told us how to treat patients. Often it is even pre-Guttenberg technology dependant (hand written).
• This paradigm was implemented in EHRS: PMH, CC, Social Hx, HPI, etc. etc.
• This paradigm was somewhat impacted in the 1960’s by crazy Dr. Larry Weed
• Every 50 years we need to re-think how we think of patients.• We use information and generate information and actions.
Information used is typically current problems/medications, HPI, and ROS/PE.
Actions are surgery, medical therapy, psychotherapy We translate what we know into what we do. This defines us and our
profession. So lets formalize it in a model which is optimized to support this
From Kevin
Page 22
What We Know (information) and what we do (actions)• A Health Concern can be linked to any relevant data: labs,
encounters, medications, care plan A Health Concern POV looks like a long hall way, with doors to
rooms with all kinds of crap in them. You can, if you read the door name (aka Observaiton.code) query for all of the relevant data (and graph it is numeric, etc.).
At any given instant, what we know is effectively what is in the health concern, and the H&P/initial nursing assessment.
At a given point we have enough information to take action. This action is captured in the Care Plan. Diagnosis or identified problems/concerns then get updated.
For every plan of care there better be some health concern!
From Kevin
Page 23
CARE PLAN AND HEALTH CONCERN
• Care plans need goals, i.e. tries to cause some ObservationEvent to match it.
• Care plan has intimate relationship with HealthConcern—is is the reason for the care plan
• Can view things via the HealthConcern POV, CarePlan POV, the individual encounter POV, and Health Summary (extraction/view)
fCare Plan: set of ongoing and future actions GOAL
Health ConcernRecords what Happens
From Kevin
Page 26
Action Items as of 2011-04-20
No. Action Items By Whom For When Status
2. Do an inventory of use cases and storyboard on hand Laura (Danny) Active: Underway
3. Ask William for an update (add in a diff colour to the appropriate pages) André Outstanding - Request made
5 Obtain and share the published version of the CEN Continuity of care P1 and P2; obtain ok from ISO
Audrey/Laura Outstanding
7 Update new wiki page with previous meeting material. Adjust structure of wiki. André Wiki restructured
8 Draft list of deliverables for this phase André Draft prepared
9 Draft a new PSS and review with project group André Deferred
10 Initiate draft of requirements André Started
11 Prepare draft storyboard for one situation using HDF 1.5 Danny
12
13
14
NB: Completed action items have been removed.
Page 28
Review of draft list/description of deliverables• See wiki: HL7_PCWG_CarePlanDeliverables-Draft-20110405a.doc
Business Requirements, Scope and Vision Standards context Storyboards and Use Cases Interaction diagram Process Flow Domain Glossary Information Model Business triggers and Rules
• Diagram of health concerns/problems and care plan on a timeline? State machine diagram applied to concerns?? Lifecycle? Status of acts, referrals Continuity of care timeline
• Harmonization (should be in parallel to produce the above to minimize rework)
2011-04-06
Page 29
Care Plan Development - Principles• High level processes can be used to guide storyboards, use cases and
care plan structure development and activity diagram and interaction diagram
• Care plan should preferably be problem/issue oriented, although may need to be reason-based where problem/issue not applicable, e.g. health promotion or health maintenance as reason. Use ‘health concern’ as encompassing term? (see Care Provision, 2006-7)
• Care plan should be goal/outcome oriented- to allow measurement• Interventions are goal/outcome oriented
• External care plan(s) can be linked to specific intervention/care services• Goal/outcome criteria are essentially for assessment of
adequacy/effectiveness of planned intervention or service• Reason for care plan is for guiding care and for communication among
care participants. Need to support exchange of information.
Stephen Chu5 April 2011
2011-04-06
Page 30
Definition of Care Plan on Wiki
• The Care Plan Topic is one of the roll outs of the Care Provision Domain Message Information Model (D-MIM). The Care Plan is a specification of the Care Statement with a focus on defined Acts in a guideline, and their transformation towards an individualized plan of care in which the selected Acts are added.
• The purpose of the care plan as defined upon acceptance of the DSTU materials in 2007 is: To define the management action plans for the various conditions (for example
problems, diagnosis, health concerns)identified for the target of care To organize a plan for care and check for completion by all individual professions
and/or (responsible parties (including the patient, caregiver or family) for decision making, communication, and continuity and coordination)
To communicate explicitly by documenting and planning actions and goals To permit the monitoring, and flagging, evaluating and feedback of the status of
goals, actions, and outcomes such as completed, or unperformed activities and unmet goals and/or unmet outcomes for later follow up
Managing the risk related to effectuating the care plan,
• Source: http://wiki.hl7.org/index.php?title=Care_Plan_Topic_project
Page 31
Care Plan – High Level Processes
Stephen Chu5 April 2011
Identify problems/issues/reasons
Assess impact/severity: referral order tests
Initial Assessment
Confirm/finalize problem/issue/reason list
Determine goals/intended outcomes
Determine Problems & Outcomes
Set outcome target date
Determine/plan appropriate interventions
Determine/assign resources healthcare providers other resources
Develop Plan of Care
Implement interventions
Care Plan Implementation
Evaluate patient outcome
Review interventions
Evaluation
Document outcomes
Revise/modify interventions
OR
Close problem/issues/reason/care plan
Follow-up Actions
Goals/Outcomes:- Optimize function - prevent/treat symptoms - improve functional capability - improve quality of life- Prevent deterioration - prevent exacerbation; and/or - prevent complications- Manage acute exacerbations- Support self management/care
Care Plan
This is based on a broad review.All converge.
May need to revise goals and outcomes during the process ofcare.
Nutrition has similar model. Also use standardized language
Hierarchy or interconnected plans can apply.
Every prof group has specific ways to deliver care. Here we focus on the overall coordination of care.
Is there always a care coordinator?Patients could be the coordinator of their own care. They should beactive participants.This diagram is about process, notInteractions and actors
Add care coordination activitiesin these activities
Need a concept of a master care planwith all the concerns and problems
From April 6th
Page 32
Care Plan – Process-based Structure
Stephen Chu5 April 2011
Identify problems/issues/reasons
Assess impact/severity: referral order tests
Initial Assessment
Confirm/finalize problem/issue/reason list
Determine goals/intended outcomes
Determine Problems & Outcomes
Set outcome target date
Determine/plan appropriate interventions
Determine/assign resources healthcare providers other resources
Develop Plan of Care
Implement interventions
Care Plan Implementation
Evaluate patient outcome
Review interventions
Evaluation
Document outcomes
Revise/modify interventions
OR
Close problem/issues/reason/care plan
Follow-up Actions
Goals/Outcomes:- Optimize function - prevent/treat symptoms - improve functional capability - improve quality of life- Prevent deterioration - prevent exacerbation and/or - prevent complications- Manage acute exacerbations- Support self management/care
Care Plan
Diagnosis/problem/issue - primary - secondary …
Problem/issue/risk/reason Desired goal/outcome Outcome target date
Planned intervention/care service Planned intervention datetime/time interval (including referrals) links to other care plan as service plan Responsible healthcare & other provider(s)
Intervention review datetimeResponsible review party/parties
Review outcome
Review recommendation/decision
Need a master plan with linkages to sub-plansSame as the problem list
2 levels: global that everyone Can see: what by whom. Then a detail
Need to decide what tool to use for the next version
From April 6th
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