/
Care Plan (CP) Team Meeting Notes Care Plan (CP) Team Meeting Notes

Care Plan (CP) Team Meeting Notes - PowerPoint Presentation

lois-ondreau
lois-ondreau . @lois-ondreau
Follow
352 views
Uploaded On 2019-06-29

Care Plan (CP) Team Meeting Notes - PPT Presentation

As updated during meeting André Boudreau aboudreauboroanca Laura Heermann Langford LauraHeermannimailorg 20110420 No 10 HL7 Patient Care Work Group Agenda for April 20 Preparation for WGM in ID: 760724

plan care hl7 health care plan health hl7 patient outcomes problem outcome prevent interventions determine clinical reason review goals

Share:

Link:

Embed:

Download Presentation from below link

Download Presentation The PPT/PDF document "Care Plan (CP) Team Meeting Notes" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.


Presentation Transcript

Slide1

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

André Boudreau (a.boudreau@boroan.ca)Laura Heermann Langford (Laura.Heermann@imail.org)2011-04-20 (No. 10)

HL7 Patient Care Work Group

Slide2

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

Slide3

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)

Slide4

Participants- Meetg of 2011-04-20 p1

Name

email

Country

Yes

Notes

André Boudreau

a.boudreau@boroan.ca

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

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

L

ead Clinical Information Architecture; co-chair HL7 Patient care WG; vice-chai

r 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

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

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

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

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

Yes

Ocean Informatics .

Health

informatics

specialist

;

Formal

general

medical

practitioner

;

OpenEHR

;

Slovakia

Pediatrics

EMR; Sweden

distributed care approach

Danny

Probst

Daniel.Probst@imail.org

US

Yes

Intermountain Healthcare.

Data Manager

Kevin Coonan

Kevin.coonan@gmail.com

US

Yes

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. Specialist Master Consultant at Deloitte. HL7 Dynamic Care Plan Co-developer

Elayne

Ayres

EAyres@cc.nih.gov

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

Slide5

Participants- Meetg of 2011-04-20 p2

Name

email

Country

Yes

No

Notes

David Rowed

david.rowed@gmail.com

AU

Charlie Bishop

charlie.bishop@isofthealth.com

UK

Walter Suarez

walter.g.suarez@kp.org

US

Yes

Peter

Hendler

Peter.Hendler@kp.org

US

Ray Simkus

ray@wmt.ca

CA

Lloyd

Mackenzie

lloyd@lmckenzie.com

CA

LM&A Consulting Ltd.

Serafina

Versaggi

serafina.versaggi@gmail.com

US

Yes

Sasha Bojicic

SBojicic@infoway-inforoute.ca

CA

Lead architect,

Blueprint 2015,

Canada Health Infoway

Agnes Wong

awong@infoway-inforoute.ca

CA

RN,

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

Valeri

e Leung

vleung@infoway-inforoute.ca

CA

Pharmacist. Clinical Leader, Canada Health Infoway

Slide6

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.

Slide7

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

Slide8

Care Plan – High Level Processes

Slide9

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

Slide10

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

Slide11

Care Plan – High Level Processes

Stephen Chu

12 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 Plan

Determine/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

Slide12

Care Plan – Process-based Structure

Stephen Chu

12 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 datetime

Responsible 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

Slide13

Storyboards

Slide14

Storyboard: what is it?

Narrative of business (clinical; administrative) processes on domain/area of interestNon technical (conceptual in nature)Describes:Activities, interactions, workflowsParticipantsHigh level data contents feeding into or resulting from processesProvides inputs for:Activity diagramsInteraction diagramsState transition diagramsHigh level class diagrams

Stephen Chu

12 April 2011

Slide15

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

Slide16

IHE Patient Plan of Care (PPOC)

Deferred

Slide17

Modeling Tool to Use

Responses from Lloyd Mackenzie and Jean DuteauBoth use Enterprise Architect (EA)Response from Andy Stechishin, HL7 Tooling and V3 Publishing co-chairFirst, 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-insRecommended by HL7Open 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 startAdel agreed to help us thereAndré will find a resourceThe tool will be used to do:Use casesActivity and workflow diagramsInteraction diagramsClass models

Includes post-meeting notes

Slide18

Issue: What overarching term to use?

Condition

Health concern and care Plans

Slide19

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

Slide20

‘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

Slide21

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 WeedEvery 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, psychotherapyWe 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

Slide22

What We Know (information) and what we do (actions)

A Health Concern can be linked to any relevant data: labs, encounters, medications, care planA 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

Slide23

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 planCan 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

Slide24

Requirements

Slide25

Conclusion

Slide26

Action Items as of 2011-04-20

No.Action ItemsBy WhomFor WhenStatus2.Do an inventory of use cases and storyboard on handLaura (Danny)Active: Underway3.Ask William for an update (add in a diff colour to the appropriate pages)AndréOutstanding - Request made5Obtain and share the published version of the CEN Continuity of care P1 and P2; obtain ok from ISOAudrey/LauraOutstanding7 Update new wiki page with previous meeting material. Adjust structure of wiki.AndréWiki restructured8Draft list of deliverables for this phaseAndréDraft prepared9Draft a new PSS and review with project groupAndréDeferred10Initiate draft of requirementsAndréStarted11Prepare draft storyboard for one situation using HDF 1.5Danny121314

NB: Completed action items have been removed.

Slide27

Appendix

Slide28

Review of draft list/description of deliverables

See wiki: HL7_PCWG_CarePlanDeliverables-Draft-20110405a.docBusiness Requirements, Scope and VisionStandards contextStoryboards and Use CasesInteraction diagramProcess FlowDomain GlossaryInformation ModelBusiness triggers and RulesDiagram of health concerns/problems and care plan on a timeline?State machine diagram applied to concerns?? Lifecycle? Status of acts, referralsContinuity of care timelineHarmonization (should be in parallel to produce the above to minimize rework)

2011-04-06

Slide29

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 diagramCare 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 measurementInterventions are goal/outcome orientedExternal care plan(s) can be linked to specific intervention/care servicesGoal/outcome criteria are essentially for assessment of adequacy/effectiveness of planned intervention or serviceReason 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

Slide30

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

Slide31

Care Plan – High Level Processes

Stephen Chu

5 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 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

Add care coordination activities

in these activities

Need a concept of a master care plan

with all the concerns and problems

From April 6th

Slide32

Care Plan – Process-based Structure

Stephen Chu

5 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 datetime

Responsible review party/parties

Review outcome

Review recommendation/decision

Need a master plan with

linkages to sub-plans

Same 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