Care Plan (CP) Orlando WGM Meeting (With meeting notes)

Care Plan (CP) Orlando WGM Meeting(With meeting notes)

André Boudreau (a.boudreau@boroan.ca)

Stephen Chu (mailto:stephen.chu@nehta.gov.au)

Laura Heermann Langford (Laura.Heermann@imail.org)

2011-05-19, Q1, 9h00 to 10h30Care Plan wiki: http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011

HL7 Patient Care Work Group

There are facilities for remote participation for those who cannot be in Orlando:Teleconference: Call number: 770-657-9270, PIN 398644Webex (thanks to Canada Health Infoway): https://infoway-inforoute.webex.com/infoway-inforoute/j.php?ED=160071542&UID=494535562&RT=NCMxMQ%3D%3D

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Agenda - May 19th – Q1- 9h00 to 10h30

• Attendance and agenda check – Stephen/Laura (5)• Background: history, need for a Care Plan DAM -André (5)• Approach followed /deliverables – André (10)• Status of Care Plan DAM project - André (5)• Storyboard review: chronic care, home care - Laura (15)• Sample of discussions: models, structures - Laura (15)• Identifying key resources for the Care Plan DAM project – All

participants (15) Material and people from other Patient Care work (Pressure Ulcer,

DCM) and other WG (Emergency Care, Care Provision, Care Statement, Structured Document, CDA consolidation, etc.)

• Suggestions and concerns of participants - Laura (15)• Close -Laura (5)

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Participants- WGM Meetg of 2011-05-19 p1*Name email Country Yes Notes

André Boudreau a.boudreau@boroan.ca CA YesCo-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 Laura.Heermann@imail.org 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 stephen.chu@nehta.gov.au 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 peter.macisaac@hp.com AU HP Enterprise Services. MD; Clinical Informatics Consultant; IHE Australia; Medical Practitioner - General Practice

Adel Ghlamallah aghlamallah@infoway-inforoute.ca CA Canada Health Infoway. SME at Infoway (shared health record); past architect on EMR projects

William Goossen wgoossen@results4care.nl NL Yes 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 agoossen@results4care.nl NL Yes 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 ian.townend@nhs.net UK NHS Connecting for Health. Health Informatics; Senior Interoperability Developer, Data Standards and Products; HL7 Patient Care Co-Chair

Rosemary Kennedy Rosemary.kennedy@jefferson.edu 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 jaylyle@gmail.com US JP Systems. Informatics Consultant; Business Consultant & Sr. Project Manager

Margaret Dittloff mkd@cbord.com US The CBORD Group, Inc.. RD (Registered Dietitian); Product Manager, Nutrition Service Suite; HL7 DAM project for diet/nutrition orders; American Dietetic Association

Audrey Dickerson adickerson@himss.org 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 Ian.McNicoll@oceaninformatics.com UK Ocean Informatics . Health informatics specialist; Formal general medical practitioner; OpenEHR; Slovakia Pediatrics EMR; Sweden distributed care approach

Danny Probst Daniel.Probst@imail.org US Intermountain Healthcare. Data Manager

Kevin Coonan Kevin.coonan@gmail.com US MD. Emergency medicine. HL7 Emergency care WG.

Gordon Raup graup@datuit.com US CTO, Datuit LLC (software industry).

Susan Campbell bostoncampbell@mindspring.com US Yes PhD microbiologist. Principal at Care Management Professionals. HL7 Dynamic Care Plan Co-developer

Elayne Ayres EAyres@cc.nih.gov US YesNIH 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

*: includes on site and teleconference participants

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Participants- WGM Meetg of 2011-05-19 p2Name email Country Yes Notes

David Rowed david.rowed@gmail.com AUCharlie Bishop charlie.bishop@isofthealth.com UK YesWalter Suarez walter.g.suarez@kp.org USPeter Hendler Peter.Hendler@kp.org USRay Simkus ray@wmt.ca CALloyd Mackenzie lloyd@lmckenzie.com CA LM&A Consulting Ltd.Serafina Versaggi serafina.versaggi@gmail.com US Clinical Systems Consultant Sasha Bojicic SBojicic@infoway-inforoute.ca CA Lead architect, Blueprint 2015, Canada Health Infoway

Agnes Wong awong@infoway-inforoute.ca CARN, BScN, MN, CHE. Clinical Adoption - Director, Professional Practice & Clinical Informatics, Canada Health Infoway

Cindy Hollister chollister@infoway-inforoute.ca CA RN, BHSc(N), Clinical Adoption -Clinical Leader, Canada Health Infoway

Valerie Leung vleung@infoway-inforoute.ca CA Pharmacist. Clinical Leader, Canada Health Infoway

Luigi Sison lsison@yahoo.com US YesInformation Architect at LOINC and at HL7. Enterprise Data Architect at VA. Developing standard for Detailed Clinical Models (DCM), information models for Electronic Health Record (EHR) Diabetes Project, etc.

Brett Esler brett.esler@pencs.com.au AU Yes Pen Computer Sys

Catherine Hoang catherine.hoang2@va.gov US Yes VA

Hugh Leslie hugh.leslie@oceaninformatics.com YesSam Heard sam.heard@oceaninformatics.com Yes

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BACKGROUND

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History and Need for CP DAM

• Care Plan has been balloted some years ago as DSTU. However, it was felt at that time that more work needed to be done in defining care plan, the components of the care plan, identifying use cases and use.

• Items about Care Planning to be discussed towards a future round of DSTU include: Existing RMIM: does it cover all kinds of care plans and

pathways. Definition of care plan The overall structure that has been agreed: Care Plan ->

Order set -> Clinical Statement. Discussion about this hierarchy is done in PC, O&O and CDS WG.

Source: HL7 Patient Care WG Wiki

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Project Scope (2010) – to Be Updated• 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, Generally a care plan greatly aids the team (responsible parties –

it could be the patient caregiver/family) in understanding and coordinating the actions that need to be performed for the person.

• The Care Plan structure is used to define the management action plans for the various conditions identified for the target of care.

• It is the structure in which the care planning for all individual professions or for groups of professionals can be organized, planned and checked for completion.

• Communicating explicitly documented and planned actions and goals greatly aids the team in understanding and coordinating the actions that need to be performed for the person.

• Care plans also permit the monitoring and flagging of unperformed activities and unmet goals for later follow up.

Source: HL7 Patient Care WG Wiki - Care Plan Topic project (Archived)

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Discussion Notes (Background)

• Focus on requirements• Do not worry about RMIM for 2 years• Issue

Contents are derivation from RIM components, F class Should not find anything that is not covered in the RIM D-MIM is top

o Informed by use caseso CP DAM is key to validate our DMIM

Care Provision DMIM is Top Level HL7 artifact for CP Domain. Clinical Statement will be used in the future Copy what is useful from past work

• Plan Walkthrough of DSTU and other existing material at a future meeting by William (André/Laura to schedule)

• Patient Care WG has 18 projects

Stephen/Laura/William to validate these notes

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APPROACH AND DELIVERABLES

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Approach

• The plan for 2011 is to first develop a Domain Analysis Model (DAM) for the Care Plan, and then decide on follow on activities.

• The HDF 1.5 (HL7 development framework) approach will be followed.

• HL7 PC will work together with various groups including HL7 Work Groups (e.g. EHR, Structured documents), IHE, NEHTA, Canada Health Infoway, and others.

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HDF- Domain Analysis Overview act 3: Domain Analysis Ov erv iew

Analyze Business Context

(from 3.4.1 Business Context Analysis)

Analyze Use Cases

(from 3.4.2 Use Case Analysis)

Analyze Process Flow

(from 3.4.3 Process Analysis)

Analyze Information Exchanged

(from 3.4.4 Information Analysis)

Analyze Business Rules

(from 3.4.5 Business Rules Analysis)

Story board

(from 3.7 Artifacts)

Use Case Analysis

(from 3.7 Artifacts)

Process Flow

(from 3.7 Artifacts)

Information Model (Analysis)

(from 3.7 Artifacts)

Glossary

(from 3.7 Artifacts)

«optional»Business Rules Description

(from 3.7 Artifacts)

Business Trigger Analysis

(from 3.7 Artifacts)

DAM Approv al

Publish DAM

ProjectApproved

Business Requirements

«outcome»«outcome»

Source: HDF_1.5.doc, page 37

Last updated: 2011-02-09

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Requirements Document- Structure

• Business and clinical context, overall need• Definition of the topic (theme)• Stakeholders and needs• Overall description of processes: contents dynamic,

interchange• Interrelationships with other processes• Scope (in and out)• Business objectives and outcomes• Vision Statement

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Discussion Notes (Approach and Deliverables)

• Care Plan can be dynamic and also have static moments• Important to be pragmatic to achieve results in reasonable

time Coordination of care is the key Keep things simple otherwise we will be caught in a lot of

complexity• Understand context and stakeholders needs• We will not focus on the process of developing care plan

There are 100’s of ways of developing CPs But the interoperable info has to accommodate all this We are modeling mostly the data-elements, not all of the process,

only the moodcodes (RQO, GOL, INT, EVN) might be sufficient for the process.

Stephen/Laura/William to validate these notes

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PROGRESS AND STATUS OF CP DAM PROJECT

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Regular Participants at Weekly Meetings

• André Boudreau, Co-Lead• Laura Heermann Langford, Co-Lead• Stephen Chu, Patient Care WG Co-Chair• Susan Campbell• Kevin Coonan• Margaret Dittloff• Adel Ghlamallah• Rosemary Kennedy• Jay Lyle• Ian McNicoll• Danny Probst• Luigi Sison, modeller

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Progress Achieved

• We clarified the process we would follow to conduct the Care Plan Domain Analysis

• We identified the storyboards required to cover the range of situations to be covered in the DAM

• We developed / refined 2 storyboards Chronic care Home Care

• We discussed and modeled the dynamics of care plans

• We looked at and compared the contents of some care plans: Sweden, IHE, NEHTA, Nursing

• We started drafting requirements

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STORYBOARD REVIEW• Chronic Care• Home Care

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List of Required Care Plan Storyboards

• Chronic Care• Acute Care• Home Care• Perinatology• Pediatric and Allergy/Intolerance• Stay healthy/ health promotion

• Sources: IHE, CHI, HL7, etc.• This is the starter set. Is it sufficient?

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Guiding Principles for Storyboards

• Describe a specific healthcare business problem (or processes) that require(s) the exchange of data/information

• By clinicians• Need to ensure

Readability Clinical accuracy, validity Coverage (focus on the 80%, not the exceptions)

• Refined as we progress in the DAM process Remember: storyboards get improved over time, as the

project advances

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SAMPLE OF DISCUSSIONS REGARDING CARE PLAN DAM

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Dynamic Federated Plan of Care Model provided by Laura

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Discussion Notes (Dynamic Plan of Care)

• ONC Transition of Care initiative Care Plan topic: exchange of information and knowledge Very time driven HIN- 3 use cases: simple discharge, simple referral,

Laura to augment

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Dynamic Federated Plan of Care Model provided by Laura- Discussion• This model illustrates a collaborative care model where the

care plan is dynamically updated and maintained by multiple organizations and providers Referral is connected to the plan

• The pink line shows the flow when there is no federated care plan What is to be transmitted? The whole contents? Or the latest and

most relevant data for the target organization/provider?• We need to look at a typical chronic disease case where

multiple organizations are involved without a federated care plan and no common system

• Sweden is moving to a patient centric model with a central dynamic care plan with greater fluidity of information among providers

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Types of care plans (provided by Stephen)• Dynamic care plans

Care plans that are developed, shared, actioned and revise realtime by participating care providers via a collaborative (likely to be web-based) care plan management environment supported by complex workflow management engine.o dynamic and organico coordinated by care coordinator (e.g. GP)o shared realtimeo updated/managed realtime by all care providero can contain other care planso dynamic links to relevant patient information (where appropriate and feasible, i.e.

privacy and security permit) and evidence-based resources• Interchanged care plans

Care plans that are shared (preferrably via electronic exchanges) and actioned by participating care providerso lack support of a realtime collaborative care plan management environmento master care plan managed and updated/maintained mainly by a care coordinator

(e.g. GP) with contributions from participating care providerso interchanged care plan is essentially a snap shot of the master care plan at a point

in timeo communicated often together with referral/request for services to target care

providerso can contain other care plans as attachments

Created: 2011-03-09

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Discussion Notes (Dynamic/Interchanged Care Plans

• Sam:• Charlie:• Susan: how is the information exchanged: real time?

VS CDA nested information On a selective basis

Stephen/Laura to add notes

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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

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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

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Discussion Notes (High Level Processes)

• Versioning must be allowed Proposed and accepted Care Plans may be different

o Required approval by care giver, patiento Implicit approval? Or explicit

Key with static CPs• Ensure that the patient is central to the process

Vs provider centric Both approaches should be allowed? Patient control? Preferences?

• Financial responsibility implied?• NL mental health: central CP to individual CP

Institution resources vs patient needs• Each country has their process• Patient care DMIM: Patient can be author of CP• Laura to add discussion notes?

Stephen/Laura to add notes

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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.

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KEY RESOURCES FOR THE CARE PLAN DAM PROJECT

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Material and People

Source Material People Notes

Patient Care-DCM

Patient Care-CP DSTUPatient care-Pressure UlcerCare Statement

Care Provision

Structured Document

CDA

Templates

Emergency care

EHRS FM

PHRS FM

FM Profiles

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Discussion Notes- Key Resources for the Care Plan DAM Project

• DAM for devices• DAM CIC CV• ISO CONSYS work• Danish EHR project; combining dynamics and

statics: http://www.openecg.net/WS1_slides/S3_3_kvrneland/S3_arn

e.pdf• In the EHR-S FM and the PHR-S FM there are

functionalities about the care plan. Maybe its helpful to have a look at it, because it says something about the behavior of the system

• ISO standard for the Care Plan: definition, see http://wiki.hl7.org/index.php?title=Care_Plan_Glossary

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SUGGESTIONS AND CONCERNS

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Suggestions and Concerns

• AU project Uses DSTU material Some issues: what are they? Specific functions and attributes DAM work is good Need clarification of static vs dynamic

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CONCLUSION

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Concluding Notes

• Reminder: Care Plan DAM weekly meetings Wednesday, 17h00 EDT, 1.5 to 2 hours = 11h00 PM in NL All are welcome

• HL7 Wiki: Patient Care WG/ Care Plan Initiative 2011

Laura/Stephen to verify