Transcript Slide 1

Note 1: see April 13th preliminary agenda on slide 5.
Note 2: see notes received by email on page 12 and
new Appendix 1 on Health Concern (by Kevin)
Care Plan (CP) Team Meeting Notes
(As updated during meeting)
André Boudreau ([email protected])
Laura Heermann Langford ([email protected])
2011-04-06 (No. 8)
HL7 Patient Care Work Group
Participants- Meetg of 2011-04-06 p1
Name
email
Country
Yes
André Boudreau
[email protected]
CA
Yes
Laura Heermann Langford
[email protected]
US
Yes
Stephen Chu
[email protected]
AU
Yes
Peter MacIsaac
[email protected]
AU
Yes
Adel Ghlamallah
[email protected]
CA
Yes
William Goossen
[email protected]
NL
Anneke Goossen
[email protected]
NL
Ian Townsend
[email protected]
UK
Rosemary Kennedy
[email protected]
US
Jay Lyle
[email protected]
US
Margaret Dittloff
[email protected]
US
Audrey Dickerson
[email protected]
US
Ian McNicoll
[email protected]
UK
Danny Probst
[email protected]
US
Yes
Kevin Coonan
[email protected]
US
Yes
Gordon Raup
[email protected]
US
Yes
No
Notes
Yes
.
Page 2
Participants- Meetg of 2011-04-06 p2
Name
email
Country
Yes
No
Notes
David Rowed
[email protected]
AU
Charlie Bishop
[email protected]
UK
Walter Suarez
[email protected]
US
Peter Hendler
[email protected]
US
Ray Simkus
[email protected]
CA
Elayne Ayres
[email protected]
US
Lloyd Mackenzie
[email protected]
CA
Serafina Versaggi
[email protected]
US
Sasha Bojicic
[email protected]
CA
Lead architect, Blueprint
2015, Canada Health Infoway
LM&A Consulting Ltd.
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
Page 3
Agenda for April 6th
• Review of Stephen’s slides on processes, structure
and principles
• Review of Care Plans comparison provided by Ian
• Review of IHE Patient Plan of Care by Jay
• Review of draft list/description of deliverables
(André)
• Identify agenda items for WGM in Orlando
 Who will be there?
 We seem to have 1.5 hour
• Updated status on the wiki and uploaded documents
• Update from Danny on use cases
• Agenda for next meeting
Page 4
Agenda for April 13th
• Storyboard criteria (Laura, Stephen, Danny) [see slide 20]
• Care Plan elements from KP, Intermountain, etc. (Laura)
• Business requirements: summary of key aspects since
February (André)
 This will become eventually our first formal deliverable: tentative
structure:
o
o
o
o
o
o
o
o
Business and clinical context, overall need
Definition of the topic (theme)
Stakeholders and needs
Overall description of processes: contents dynamic, interchange: integrate Laura’s and Stephen’s models
Interrelationships with other processes (context diagram)
Scope (in and out)
Business objectives and outcomes
Vision Statement
• Introduction to Eclipse Workbench (Kevin): download and
quick start
• Updated high level processes (Stephen) [done]
• IHE Patient Plan of Care (PPOC)?
Page 5
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 6
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 7
Need to decide what tool to use for the next version
Care Plan – Process-based Structure
Initial Assessment
Identify problems/issues/reasons
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
Assess impact/severity:
 referral
 order tests
Diagnosis/problem/issue
- primary
- secondary …
Determine Problems & Outcomes
Problem/issue/risk/reason
Confirm/finalize problem/issue/reason list
Desired goal/outcome
Outcome target date
Determine goals/intended outcomes
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
Set outcome target date
Develop Plan of Care
Determine/plan appropriate interventions
Determine/assign resources
 healthcare providers
 other resources
Care Plan Implementation
Implement interventions
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
Care Plan
Evaluation
Evaluate patient outcome
Review interventions
Follow-up Actions
Review outcome
Document outcomes
Revise/modify interventions
Review recommendation/decision
OR
Stephen Chu
5 April 2011
Close problem/issues/reason/care plan
Page 8
Care Plan – Process-based Structure
Initial Assessment
Care orchestration
Identify problems/issues/reasons
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
Assess impact/severity:
 referral
 order tests
Determine Problems & Outcomes
High Level Shared Plan
Problem/concern/reason 1..*
Target goals/outcomes
Planned intervention
Assessed outcome
Confirm/finalize problem/concern/reason list
Determine goals/intended outcomes
Set outcome target date
Problem/issue/risk/reason
Desired goal/outcome
Outcome target date
Develop Plan of Care
Determine/plan appropriate interventions
Care
orchestration
Refer to other provider (s)
Determine/assign resources
Planned intervention/care service
Planned intervention datetime/time interval
(including referrals)
links to other care plan as service plan
Responsible healthcare & other provider(s)
 healthcare providers
 other resources
Care Plan Implementation
Implement interventions
Evaluation
Care Plan
Intervention review datetime
Responsible review party/parties
Evaluate patient outcome
Review interventions
Follow-up Actions
Document outcomes
Review outcome
Revise/modify interventions
OR
Stephen Chu
12 April 2011
Review recommendation/decision
Close problem/issues/reason/care plan
Page 9
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 10
Comparison of Care Plan Elements (Ian)
• See Xmind map: HL7 Care Plan- Models comparison- Sweden IHE NEHTA.xmind
• Sweden, IHE PCCP, NEHTA, IHE Nursing and aligned model
• Excellent work and tool
• Add a few more: find examples that are used a lot




KP?
VA?
Intermountain?
Mayo?
• Laura has direct contacts
 Danny and Laura to add to the analysis
Page 11
IHE PCCP IHE (from March 23rd)
• Peter and Laura connected and reviewed what IHE did
 Included AU work done
• Key documents: need to extract business requirements and
principles
 PCCP Patient Centered Coordination Plan (Ian- compare to Swedish)
o Scoped back for the USA
o Full version
 Patient Plan of Care: for nursing (Jay)
 eNursing summary (Peter and Stephen)
•
•
•
•
Volume 1 and 2: IHE specific constructs: may not be useful
Get ok from IHE that we can post on wiki: pdf versions?
Some harmonization would be required
May need to consider 2 architectures: one central dynamic CP,
and a series of CP interconnected
Page 12
IHE Nursing plan of care
• Not adequate
• Incomplete
• See Jay’s deck
• IHE focus is on the exchange of documents, mainly
HL7 CDA
Page 13
Notes sent by email- April 6th
• 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.
Page 14
Review of draft list/description of
deliverables
•
•
•
•
•
•
•
•
•
See wiki: HL7_PCWG_CarePlanDeliverables-Draft-20110405a.doc
Business Requirements, Scope and Vision
Standards context
Storyboards and Use Cases
Process Flow
Domain Glossary
Information Model
Business triggers and Rules
Harmonization (should be in parallel to produce the above to
minimize rework)
• Interaction diagram
• 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
Page 15
Tools that we will use
•
•
•
•
Word
Excel
Power Point
HL7 Eclipse (Open source), very powerful and MDA
 Who will guide us: Kevin
• Select tool that XML open source
• No: Enterprise Architect (for all models)
• ? Xmind (for brainstorm?)
 Can export to FreeMind
• Are there standard templates somewhere for Word, Excel?
• Or do we create our own?
Page 16
Agenda for Orlando WGMs
• Time available for care plan:
 Thursday, Q1
 May have a bit more time (allergy Q)
 Add Q5 on one or more days
• Who is attending?
 André, Laura, Kevin, Margaret, Stephen?, William
 Unlikely: Peter, Adel
• Our focus?
 TBD
Page 17
Notes on restructured wiki page
• Add team members that are regulars. Include
profile notes.
Page 18
Danny’s work on story boards (from
March 23rd)
• 4 areas of hi priorities




Perinatalogy
Chronic illness
Home health
Acute
• Trying to make them similar
• Allergies and intolerance: is this relevant to us?


Add a complicated scenario: primary care treatment plus a referral (Ian)
Stephen: [17:50:18] Stephen Chu: allergy and intolerance can produce a care plan of its own, e.g.
coeliac disease, but I agree that we can embed it in all other care plans
• It would be useful to have a long term use case: see COPD
• We need to separate the clinical contents from the infrastructure that manages the care
activities
• Not sure that we would want to build a composite use case but we should be able to
abstract principles and requirements common to all
• [17:54:53] Stephen Chu: the content details will vary, but the structure should remain
constant
• we need to differentiate the concepts - contents vs structure
• Lots of variety on different documents
• Have a matrix of what exists?
• Need an agreed way of producing storyboard: what are we trying to get out of it
(Stephen and Laura)
Page 19
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
Stephen Chu
12 April 2011
Page 20
DRAFT- Scope of 2011 Care Plan Initiative
• In scope
• Range of situations: curative,
emergency, rehabilitation, mental
health, social care, preventative,
stay healthy, etc.
• Business /clinical needs around
care planning: dynamics of
creating, updating and
communication care plans;
functional perspective; dynamics;
data exchange
• Out of scope
• Patient information
complementary to the care plan:
demographics, diagnostic,
allergies and AR,
Page 21
Action Items as of 2011-04-06
No.
Action Items
By Whom
For
When
Status
Laura
(Danny)
Active: Underway
André
Outstanding - Request
made
Audrey/Laura
Outstanding
Update new wiki page with previous meeting material. Adjust structure of wiki.
André
Wiki restructured
8
Draft list of deliverables for this phase
André
Draft prepared
9
Draft a new PSS and review with project group
André
2.
Do an inventory of use cases and storyboard on hand
3.
Ask William for an update (add in a diff colour to the appropriate pages)
5
Obtain and share the published version of the CEN Continuity of care P1 and P2;
obtain ok from ISO
7
10
11
12
13
14
NB: Completed action items have been removed.
Page 22
APPENDIX 1- HEALTH CONCERN AND
CARE PLANS
Page 23
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 24
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!
Page 25
From Kevin
CARE PLAN AND HEALTH CONCERN
Health Concern
Records what Happens
fCare 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 26
APPENDIX 2
Page 27
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 28