There are facilities for remote participation for those
There are facilities for remote participation for those who cannot be in Orlando: Teleconference: Call number: 770-657-9270, PIN 398644 Webex (thanks to Canada Health Infoway): https://infoway-inforoute.webex.com/infoway-inforoute/j.php?ED=160071542&UID=494535562&RT=NCMxMQ%3D%3D Care Plan (CP) Orlando WGM Meeting (With meeting notes) Andr Boudreau ([email protected]) Stephen Chu (mailto:[email protected]) Laura Heermann Langford ([email protected]) 2011-05-19, Q1, 9h00 to 10h30 Care Plan wiki: http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 HL7 Patient Care Work Group Agenda - May 19th Q1- 9h00 to 10h30 Attendance and agenda check Stephen/Laura (5) Background: history, need for a Care Plan DAM -Andr (5) Approach followed /deliverables Andr (10) Status of Care Plan DAM project - Andr (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) Page 2 Participants- WGM Meetg of 2011-05-19 p1* Name email Country Yes Notes Andr 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 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
[email protected] 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 [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 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 Ocean Informatics . Health informatics specialist; Formal general medical practitioner; OpenEHR; Slovakia Pediatrics EMR; Sweden distributed care approach Danny Probst [email protected] US Intermountain Healthcare. Data Manager Kevin Coonan [email protected] US 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. Principal at Care Management Professionals. HL7 Dynamic Care Plan Co-developer Elayne Ayres [email protected] US Yes 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 *: includes on site and teleconference participants Page 3 Participants- WGM Meetg of 2011-05-19 p2 Name
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] CA RN, BHSc(N), Clinical Adoption -Clinical Leader, Canada Health Infoway Valerie Leung [email protected] CA
Pharmacist. Clinical Leader, Canada Health Infoway Yes Luigi Sison [email protected] US Yes Information 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 [email protected] AU Yes Pen Computer Sys Catherine Hoang
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 Page 6 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) Page 7 Stephen/Laura/William to validate these notes 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 cases o 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 (Andr/Laura to schedule) Patient Care WG has 18 projects
Page 8 APPROACH AND DELIVERABLES Page 9 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. Page 10 Last updated: 2011-02-09 HDF- Domain Analysis Overview act 3: Domain Analysis Ov erv iew Business Requirements Source: HDF_1.5.doc, page 37
Project Approved Analyze Use Cases Analyze Business Context (from 3.4.2 Use Case Analysis) outcome (from 3.4.1 Business Context Analysis) outcome Use Case Analysis (from 3.7 Artifacts) Story board Analyze Process Flow (from 3.7 Artifacts) (from 3.4.3 Process Analysis) Process Flow (from 3.7 Artifacts)
Glossary Analyze Information Exchanged (from 3.7 Artifacts) (from 3.4.4 Information Analysis) Information Model (Analysis) (from 3.7 Artifacts) Analyze Business Rules optional Business Rules Description (from 3.4.5 Business Rules Analysis) (from 3.7 Artifacts) Business Trigger Analysis (from 3.7 Artifacts) Publish DAM DAM Approv al Page 11 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 Page 12 Stephen/Laura/William to validate these notes 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 100s 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. Page 13 PROGRESS AND STATUS OF CP DAM PROJECT Page 14 Regular Participants at Weekly Meetings
Andr 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 Page 15 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 Page 16 STORYBOARD REVIEW Chronic Care Home Care Page 17 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? Page 18
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 Page 19 SAMPLE OF DISCUSSIONS REGARDING CARE PLAN DAM Page 20 Dynamic Federated Plan of Care Model provided by Laura Page 21 Laura to augment
Discussion Notes (Dynamic Plan of Care) ONC Transition of Care initiative Care Plan topic: exchange of information and knowledge Very time driven HIN3 use cases: simple discharge, simple referral, Page 22 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 Page 23 Created: 2011-03-09 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 o o o o o dynamic and organic coordinated by care coordinator (e.g. GP) shared realtime updated/managed realtime by all care provider can contain other care plans 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 providers o lack support of a realtime collaborative care plan management environment o master care plan managed and updated/maintained mainly by a care coordinator (e.g. GP) with contributions from participating care providers o interchanged care plan is essentially a snap shot of the master care plan at a point in time o communicated often together with referral/request for services to target care providers o can contain other care plans as attachments Page 24 Stephen/Laura to add notes Discussion Notes (Dynamic/Interchanged Care Plans Sam: Charlie: Susan: how is the information exchanged: real time? VS CDA nested information On a selective basis Page 25 Care Plan High Level Processes Initial Assessment
This is based on a broad review. All converge. Identify problems/issues/reasons Assess impact/severity: referral order tests Need a concept of a master care plan with all the concerns and problems Determine Problems & Outcomes Confirm/finalize problem/issue/reason list 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 Determine goals/intended outcomes Set outcome target date Develop Plan of Care
Determine/plan appropriate interventions Add care coordination activities in these activities Determine/assign resources healthcare providers other resources Care Plan Implementation Implement interventions Care Plan Evaluation Evaluate patient outcome Review interventions Follow-up Actions Document outcomes Revise/modify interventions OR Stephen Chu 5 April 2011 May need to revise goals and outcomes during the process of care.
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 be active participants. This diagram is about process, not Interactions and actors Close problem/issues/reason/care plan Page 26 Care Plan High Level Processes Initial Assessment 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 Identify problems/issues/reasons Assess impact/severity: Care orchestration referral order tests Determine Problems & Outcomes Confirm/finalize problem/concern/reason list Determine goals/intended outcomes High Level Shared Plan Problem/concern/reason 1..* Target goals/outcomes Planned intervention Assessed outcome Set outcome target date Develop Plan of Care Determine/plan appropriate interventions Care orchestration Detailed Care Plan
Refer to other provider (s) Determine/assign resources healthcare providers other resources Care Plan Implementation Implement interventions Evaluation Care Plan Evaluate patient outcome Review interventions Follow-up Actions Document outcomes Revise/modify interventions OR Stephen Chu 12 April 2011 Close problem/issues/reason/care plan Page 27 Stephen/Laura to add notes Discussion Notes
(High Level Processes) Versioning must be allowed Proposed and accepted Care Plans may be different o Required approval by care giver, patient o 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? Page 28 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 Chu 5 April 2011 Page 29 Sample of Structure and Contents (xmind models) Ian McNicoll 2011-04-06 Page 30 Sample of Structure and Contents (xmind models) Ian McNicoll 2011-04-06
Page 31 KEY RESOURCES FOR THE CARE PLAN DAM PROJECT Page 32 Material and People Source Material People Notes Patient Care-DCM Patient Care-CP DSTU Patient care-Pressure Ulcer Care Statement Care Provision Structured Document CDA Templates Emergency care EHRS FM PHRS FM FM Profiles
Page 33 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 Page 34 SUGGESTIONS AND CONCERNS Page 35
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 Page 36 CONCLUSION Page 37 Concluding Notes Laura/Stephen to verify 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
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