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
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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
Slide2Agenda 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
Slide3Agenda 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)
Slide4Participants- 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
Slide5Participants- 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
Slide6Preparation 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.
Slide7Care 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
Slide8Care Plan – High Level Processes
Slide9Process 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
Slide10Process 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
Slide11Care 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
Slide12Care 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
Slide13Storyboards
Slide14Storyboard: 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
Slide15Storyboards
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
Slide16IHE Patient Plan of Care (PPOC)
Deferred
Slide17Modeling 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
Slide18Issue: What overarching term to use?
Condition
Health concern and care Plans
Slide19Issues
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
Slide21Health 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
Slide22What 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
Slide23Care 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
Slide24Requirements
Slide25Conclusion
Slide26Action 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.
Slide27Appendix
Slide28Review 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
Slide29Care 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
Slide30Definition 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
Slide31Care 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
Slide32Care 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