Care Plan (CP) Team Meeting Notes (As updated during meeting)

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

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

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)

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

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

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.

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

CARE PLAN – HIGH LEVEL PROCESSES

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

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

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

Care Plan – Process-based Structure




Initial Assessment

Confirm/finalize problem/concern/reason list








Evaluation

Document outcomes


OR


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



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

STORYBOARDS

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


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

IHE Patient Plan of Care (PPOC)

• Deferred

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

ISSUE: WHAT OVERARCHING TERM TO USE?• Condition• Health concern and care Plans

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

http://www.hl7.org/v3ballot/html/welcome/environment/index.html

‘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

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

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

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

REQUIREMENTS

CONCLUSION

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.

APPENDIX

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

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.


2011-04-06

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

Care Plan – High Level Processes




Initial Assessment

Confirm/finalize problem/issue/reason list











Evaluation

Document outcomes


OR


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

Care Plan – Process-based Structure




Initial Assessment

Confirm/finalize problem/issue/reason list











Evaluation

Document outcomes


OR


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

Care Plan (CP) Team Meeting Notes (As updated during meeting)

Documents

Transcript of Care Plan (CP) Team Meeting Notes (As updated during meeting)