Transcript Slide 1
See agenda for April 20 th on slide 3.
Care Plan (CP) Team Meeting Notes
(As updated during meeting)
André Boudreau ([email protected]) Laura Heermann Langford ([email protected]) 2011-04-13 (No. 9) HL7 Patient Care Work Group
Agenda for April 13th
• • • • •
Email notes from Kevin, Lloyd, William, Cecil Storyboard criteria (Laura, Stephen, Danny) Introduction to Eclipse Workbench (Kevin): download and quick start Updated high level processes (Stephen) Issue: overarching term: condition, concern, problem?
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Agenda for April 20
• • • • • • • •
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 (PPOC) (Ian) Modeling tool to use (Eclipse or EA) (André) Overarching term to use (Ian M.) Business requirements: summary of key aspects since February (André)
This will become eventually our first formal deliverable
Next meeting agenda
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Participants- Meetg of 2011-04-13 p1
Name
André Boudreau Laura Heermann Langford Stephen Chu Peter MacIsaac Adel Ghlamallah William Goossen Anneke Goossen Ian Townsend Rosemary Kennedy Jay Lyle Margaret Dittloff Audrey Dickerson Ian McNicoll Danny Probst Kevin Coonan Gordon Raup Susan Campbell Elayne Ayres
Country CA US UK US US US AU AU CA NL NL US UK US US US US US
Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Notes
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.
Co-Lead- Care Plan initiative/HL7 Patient Care WG. Intermountain Healthcare. RN PhD,: Nursing Informatics; Emergency Informatics Association, American Medical Informatics Association; IHE 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 HP Enterprise Services. MD; Clinical Informatics Consultant; IHE Australia; Medical Practitioner General Practice Canada Health Infoway. SME at Infoway (shared health record); past architect on EMR projects 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 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 NHS Connecting for Health. Health Informatics; Senior Interoperability Developer, Data Standards and Products; HL7 Patient Care Co-Chair Thomas Jefferson University School of Nursing . RN; Informatics; Associate Professor; HL7 EHR WG; HL7 Patient care WG; terminology engine for Plan of care; JP Systems. Informatics Consultant; Business Consultant & Sr. Project Manager The CBORD Group, Inc.. RD (Registered Dietitian); Product Manager, Nutrition Service Suite; HL7 DAM project for diet/nutrition orders; American Dietetic Association 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.
Ocean Informatics . Health informatics specialist; Formal general medical practitioner; OpenEHR; Slovakia Pediatrics EMR; Sweden distributed care approach Intermountain Healthcare. Data Manager MD. Emergency medicine. HL7 Emergency care WG. CTO, Datuit LLC (software industry).
PhD microbiologist. Specialist Master Consultant at Deloitte. HL7 Dynamic Care Plan Co-developer 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 Page 4
Participants- Meetg of 2011-04-13 p2
Yes No Notes Name
David Rowed Charlie Bishop Walter Suarez Peter Hendler Ray Simkus Lloyd Mackenzie Serafina Versaggi Sasha Bojicic
Country AU UK US US CA CA US CA LM&A Consulting Ltd.
Agnes Wong Cindy Hollister Valerie Leung [email protected]
CA CA CA Lead architect, Blueprint 2015, Canada Health Infoway RN, BScN, MN, CHE. Clinical Adoption - Director, Professional Practice & Clinical Informatics, Canada Health Infoway RN, BHSc(N), Clinical Adoption -Clinical Leader, Canada Health Infoway Pharmacist. Clinical Leader, Canada Health Infoway Page 5
Notes sent by email- 2011-04-06
• • Kevin Coonan (1) The medication list is defined by the care plan. It is part of the therapy for a given problem.
(2) The "problem list" is largely covered as well by the care plan. If you are getting a specific therapy or plan for something, it is a problem (health concern!).
(3) We really need to determine which file formats are allowed. There are a lot of tools, many of which overlap in what software can use it, so we should be able to settle on some parsimonious set (mind map, outline, text files, information models, UML, etc.).
Lloyd McKenzie: Usually "Medication List" refers to what meds a patient is on, not what the care plan intends them to be on. The lists are often quite different. You may or may not have a care plan for a given problem. But a patient's current problem list would be of interest for all care plans.
Use these notes where applicable in our work.
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Email 1 from William 2011-04-07
• • • We have a hierarchy established and reconfirmed many times Guideline is the upper level framework Which can be expressed as critical pathway Which can be expressed in a care plan (Using the Care Plan R-MIM in Care Provision) for which we are now creating the DAM.
Which can have order sets (e.g. a section taken from the guideline and expressed as part of a care plan, e.g. a discharge planning set of activities). Which can have any kind of list (e.g. using the Care Provision Statement Collector 1 to many times, e.g. one statement collector for observation list, one SC for problem list, one for medication list, one for action plan, one for outcome indicators, one for the discharge planning etc. Each SC can get a meaningful name. This way the Care Plan R-MIM can on runtime have 100 Statement Collectors, each containing a million clinical statements….! Many many many individual care statements / clinical statements. Which is the bottom of the hierarchy Each Care Provision message can hold one or more of the above constructs 1-6. A Care Provision message can have one clinical statement, or can have 7657543 clinical statements, ordered with the above hierarchy, or as a flat series. Because most clinicians want some order we have the organizer to link some clinical statements that belong together, the statement collector to group a series of similar clinical statements and the care plan for obvious reasons to reflect practice. The guideline is more the input of knowledge to this. Response from Cecil Lynch This is not a taxonomic hierarchy but rather relationships among artifacts. Please evaluate each of these levels as an IS A statement and that will help you establish a hierarchy that is accurate.
First 3 bullets not HL7 specific. Pathway is organizational specific.
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Email 2 from William 2011-04-07
• • • • This is part of the current Normative Edition, in particular the R-MIMs and D-MIM I refer to and their explanation.
The order I suggested is not really a taxonomy as Cecil suggests, it is not completely representable in a ‘IsA’ relationship approach, it just a matter of organizing it in our heads as what is available and how is it related to each other. That part of organizing it has been discussed on several O&O and CDS and PC joint meetings of the past 3-4 years. Always on Monday Q4 meetings, where O&O has the minutes. I agree it needs to be documented and the wiki is a much better place for this. Let me do that during the WGM CP meeting. I will be there and listen. Care Statements can be organized according to the Organizer Class, according to Statement Collector(s), according to Care Plan so that is a bottom up relationship. Top down it can be as: Organizer class is a collection of 1-n different clinical statements that are usually grouped together. Assessment scale representation is a specific organizer of clinical statements that are collected and exchanged together because they are stated on the same date / time.
Statement collector is a collection of 1-n the same or similar clinical statements that are usually stated on different dates and times Care Care plan is a collection of several organizer classes representing 1-n clinical statements and / or a collection of statement collectors, and/or a collection of individual clinical statements and or other organizations of clinical statements (that is part of our current DAM work, to explore other means). Care Record R-MIM is a collection of clinical statements and/or a collection of clinical statements, such as organized care statements, care statements in statement collector(s), and/or care plan(s), and/or other collections further expressed in the R-MIM collection of the domain.
Use these notes where applicable in our work.
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Storyboard criteria
• • • • See Danny’s document as annotated during the discussion See next slide with Stephen’s input Need to align with HDF 1.5 as this was decided in a previous meetings See pages 27-28 and Appendix 1 of Power Point deck of 2011-03 02 meeting Danny will update his document and resubmit for discussion • Post meeting comment by André: suggest that the above document be restricted to Storyboards for now, since we already have the HDF 1.5 methodology document plus another document listing our deliverables for this phase Page 9
Stephen Chu 12 April 2011
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
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Care Plan Elements from KP, Intermountain, etc.
• •
Request wss sent out by Laura Some initial feedback, better to wait next week
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Introduction to Eclipse Workbench
• • • • We need to agree on a tool to do: Use cases Activity and workflow diagrams Interaction diagrams Class models 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) Ask publishing committee If Eclipse, we need some coaching to download and quick start Eclipse Add plug-in for UML Adel agreed to help us there Page 12
CARE PLAN – HIGH LEVEL PROCESSES
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Care Plan – High Level Processes
From April 6th This is based on a broad review.
All converge.
Need a concept of a master care plan with all the concerns and problems
Determine Problems & Outcomes
Confirm/finalize problem/issue/reason list Determine goals/intended outcomes Set outcome target date
Add care coordination activities in these activities
Develop Plan of Care
Determine/plan appropriate interventions Determine/assign resources healthcare providers other resources
Care Plan Implementation
Implement interventions
Care Plan Evaluation
Evaluate patient outcome Review interventions
Stephen Chu 5 April 2011 Initial Assessment
Identify problems/issues/reasons Assess impact/severity: referral order tests
Follow-up Actions
Document outcomes Revise/modify interventions OR Close problem/issues/reason/care plan
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
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
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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.
Care Plan – High Level Processes
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 orchestration Care Plan Implementation
Implement interventions
Evaluation
Evaluate patient outcome Review interventions
April 13
Initial Assessment
Identify problems/issues/reasons Assess impact/severity: referral order tests
This is illustrative
Determine Problems & Outcomes
Confirm/finalize problem/concern/reason list Determine goals/intended outcomes Set outcome target date
Develop Plan of Care
Determine/plan appropriate interventions Refer to other provider (s) Determine/assign resources healthcare providers other resources
Care orchestration High Level Shared Plan Problem/concern/reason 1..*
Target goals/outcomes Planned intervention Assessed outcome
Detailed Care Plan Care Plan Stephen Chu 12 April 2011 Follow-up Actions
Document outcomes Revise/modify interventions OR Close problem/issues/reason/care plan
Need to study this more: Laura and Susan to work on it
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Need to decide what tool to use for the next version
Care Plan – Process-based Structure
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
Need a master plan with linkages to sub-plans Same as the problem list 2 levels: global that everyone
Initial Assessment
Identify problems/issues/reasons Assess impact/severity: referral order tests
Determine Problems & Outcomes
Confirm/finalize problem/issue/reason list Determine goals/intended outcomes Set outcome target date
Can see: what by whom. Then a detail
Develop Plan of Care
Determine/plan appropriate interventions Determine/assign resources healthcare providers other resources
Care Plan Implementation
Implement interventions
Care Plan Evaluation
Evaluate patient outcome Review interventions
Stephen Chu 5 April 2011 Follow-up Actions
Document outcomes Revise/modify interventions OR Close problem/issues/reason/care plan
Diagnosis/problem/issue - primary secondary … Problem/issue/risk/reason Desired goal/outcome Outcome target date
From April 6th
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
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Will need to add explanations and maybe some different scenarios
Care Plan – Process-based Structure
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 orchestration Care Plan Implementation
Implement interventions
Evaluation
Evaluate patient outcome Review interventions
Stephen Chu 12 April 2011 Initial Assessment
Identify problems/issues/reasons Assess impact/severity: referral order tests
Determine Problems & Outcomes
Confirm/finalize problem/concern/reason list Determine goals/intended outcomes Set outcome target date
Develop Plan of Care
Determine/plan appropriate interventions Refer to other provider (s) Determine/assign resources healthcare providers other resources
Care Plan Follow-up Actions
Document outcomes Revise/modify interventions OR Close problem/issues/reason/care plan
Care orchestration High Level Shared Plan Problem/concern/reason 1..*
Target goals/outcomes Planned intervention Assessed outcome
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
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ISSUE: WHAT OVERARCHING TERM TO USE?
•
Condition
•
Health concern and care Plans
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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
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‘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
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Health concern and care plan: new paradigm to define the EHRS
From Kevin
• • • • • 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 Page 21
What We Know (information) and what we do (actions)
From Kevin
•
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!
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CARE PLAN AND HEALTH CONCERN
From Kevin
Health Concern Records what Happens f Care Plan: set of ongoing and future actions GOAL
• • • 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) Page 23
CONCLUSION
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Action Items as of 2011-04-13
No.
5 9 10 7 8 11 12 13 14 2.
3.
Action Items By Whom
Do an inventory of use cases and storyboard on hand Ask William for an update (add in a diff colour to the appropriate pages) Laura (Danny) André Obtain and share the published version of the CEN Continuity of care P1 and P2; obtain ok from ISO Update new wiki page with previous meeting material. Adjust structure of wiki.
Audrey/Laura André Draft list of deliverables for this phase André Draft a new PSS and review with project group Initiate draft of requirements André André
For When Status
Active: Underway Outstanding - Request made Outstanding Wiki restructured Draft prepared NB: Completed action items have been removed.
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APPENDIX
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Review of draft list/description of deliverables
2011-04-06
• • • 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) Page 27
Care Plan Development - Principles
2011-04-06
• 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
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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 Page 29