Transcript Slide 1
V4- With discussion notes verified and augmented as of 2011-06-10.
Includes post WGM meeting comments by Jay Lyle on Dynamic Federated Plan of Care Model.
Includes new slides for Danish model, ISO CONTSYS project, EHR-S FM R1.1 extracts for Care Plans.
Slide 36 should be filled to ensure that we don’t miss reusable material and do not reinvent contents.
Care Plan (CP) Orlando WGM Meeting
(With meeting notes)
André Boudreau ( [email protected]
) Stephen Chu ( mailto:[email protected]
) Laura Heermann Langford ( [email protected]
) 2011-05-19, Q1, 9h00 to 10h30
Care Plan wiki:
http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 HL7 Patient Care Work Group
Agenda - May 19
th
– Q1- 9h00 to 10h30
• • • • • • • • • Attendance and agenda check – Stephen/Laura (5) Background: history, need for a Care Plan DAM -André (5) Approach followed /deliverables – André (10) Status of Care Plan DAM project - André (5) Storyboard review: chronic care, home care - Laura (15) Sample of discussions: models, structures - Laura (15) Identifying key resources for the Care Plan DAM project – All participants (15) Material and people from other Patient Care work (Pressure Ulcer, DCM) and other WG (Emergency Care, Care Provision, Care Statement, Structured Document, CDA consolidation, etc.) Suggestions and concerns of participants - Laura (15) Close -Laura (5) Page 2
Participants- WGM Meetg of 2011-05-19 p1*
Name
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
US UK US US US AU AU CA NL NL US UK US US US US US Country CA
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. Principal at Care Management Professionals. 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
*: includes on site and teleconference participants
Page 3
Participants- WGM Meetg of 2011-05-19 p2*
Name
David Rowed Charlie Bishop Walter Suarez Peter Hendler Ray Simkus Lloyd Mackenzie Serafina Versaggi Sasha Bojicic Agnes Wong Cindy Hollister Valerie Leung Luigi Sison Brett Esler Catherine Hoang Hugh Leslie Seam Heard
Country AU UK US US CA CA US CA
Yes
Yes CA CA CA US AU US Yes Yes Yes Yes Yes
Notes
LM&A Consulting Ltd.
Clinical Systems Consultant 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 Information Architect at LOINC and at HL7. Enterprise Data Architect at VA. Developing standard for Detailed Clinical Models (DCM), information models for Electronic Health Record (EHR) Diabetes Project, etc.
Pen Computer Sys VA
*: includes on site and teleconference participants
Page 4
BACKGROUND
Page 5
History and Need for CP DAM
• • Care Plan has been balloted some years ago as DSTU. However, it was felt at that time that more work needed to be done in defining care plan, the components of the care plan, identifying use cases and use. Items about Care Planning to be discussed towards a future round of DSTU include: Existing RMIM: does it cover all kinds of care plans and pathways. Definition of care plan The overall structure that has been agreed: Care Plan -> Order set -> Clinical Statement. Discussion about this hierarchy is done in PC, O&O and CDS WG. Source: HL7 Patient Care WG Wiki Page 6
Project Scope (2010) – to Be Updated
• • • • • • • The Care Plan Topic is one of the roll outs of the Care Provision Domain Message Information Model (D-MIM). The Care Plan is a specification of the Care Statement with a focus on defined Acts in a guideline, and their transformation towards an individualized plan of care in which the selected Acts are added. The purpose of the care plan as defined upon acceptance of the DSTU materials in 2007 is To define the management action plans for the various conditions (for example problems, diagnosis, health concerns)identified for the target of care To organize a plan for care and check for completion by all individual professions and/or (responsible parties (including the patient, caregiver or family) for decision making, communication, and continuity and coordination) To communicate explicitly by documenting and planning actions and goals To permit the monitoring, and flagging, evaluating and feedback of the status of goals, actions, and outcomes such as completed, or unperformed activities and unmet goals and/or unmet outcomes for later follow up.
Managing the risk related to effectuating the care plan, Generally a care plan greatly aids the team (responsible parties – it could be the patient caregiver/family) in understanding and coordinating the actions that need to be performed for the person. The Care Plan structure is used to define the management action plans for the various conditions identified for the target of care. It is the structure in which the care planning for all individual professions or for groups of professionals can be organized, planned and checked for completion. Communicating explicitly documented and planned actions and goals greatly aids the team in understanding and coordinating the actions that need to be performed for the person. Care plans also permit the monitoring and flagging of unperformed activities and unmet goals for later follow up. Source: HL7 Patient Care WG Wiki - Care Plan Topic project (Archived) Page 7
Discussion Notes
(Background)
• • • • • Focus on requirements Do not worry about RMIM for 2 years Issue Contents are derivation from RIM components, F class Should not find anything that is not covered in the RIM D-MIM is top o o Informed by use cases CP DAM is key to validate our DMIM Care Provision DMIM is key Clinical Statement will be used in the future: to be proven Copy what is useful from past work Plan Walkthrough of DSTU and other existing material at a future meeting by William (André/Laura to schedule) Patient Care WG has 18 projects Page 8
APPROACH AND DELIVERABLES
Page 9
Approach
• • • The plan for 2011 is to first develop a Domain Analysis Model (DAM) for the Care Plan, and then decide on follow on activities. The HDF 1.5 (HL7 development framework) approach will be followed. HL7 PC will work together with various groups including HL7 Work Groups (e.g. EHR, Structured documents), IHE, NEHTA, Canada Health Infoway, and others. Page 10
HDF- Domain Analysis Overview
Last updated: 2011-02-09
act 3: Domain Analysis Ov erv iew Business Requirements
Project Approved
Source: HDF_1.5.doc, page 37
Analyze Use Cases
(from 3.4.2 Use Case Analysis)
«outcome»
Analyze Business Context
(from 3.4.1 Business Context Analysis)
«outcome»
Use Case Analysis
(from 3.7 Artifacts)
Analyze Process Flow
(from 3.4.3 Process Analysis)
Process Flow
(from 3.7 Artifacts)
Analyze Information Exchanged
(from 3.4.4 Information Analysis)
Information Model (Analysis)
(from 3.7 Artifacts)
Analyze Business Rules Story board
(from 3.7 Artifacts)
Glossary
(from 3.7 Artifacts)
«optional»
Business Rules Description
(from 3.7 Artifacts) (from 3.4.5 Business Rules Analysis)
Business Trigger Analysis
(from 3.7 Artifacts)
Publish DAM DAM Approv al
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Requirements Document- Structure
• • • • • • • • Business and clinical context, overall need Definition of the topic (theme) Stakeholders and needs Overall description of processes: contents dynamic, interchange Interrelationships with other processes Scope (in and out) Business objectives and outcomes Vision Statement Page 12
Discussion Notes
(Approach and Deliverables)
• • • • Care Plan can be dynamic and also have static moments Important to be pragmatic to achieve results in reasonable time Coordination of care is the key Keep things simple otherwise we will be caught in a lot of complexity Understand context and stakeholders needs We will not focus on the process of developing care plan There are 100’s of ways of developing CPs But the interoperable info has to accommodate all this We are modeling only the info, not the process Page 13
PROGRESS AND STATUS OF CP DAM PROJECT
Page 14
Regular Participants at Weekly Meetings
• • • • • • • • • • • • André Boudreau, Co-Lead Laura Heermann Langford, Co-Lead Stephen Chu, Patient Care WG Co-Chair Susan Campbell Kevin Coonan Margaret Dittloff Adel Ghlamallah Rosemary Kennedy Jay Lyle Ian McNicoll Danny Probst Luigi Sison, modeller Page 15
Progress Achieved
• • • • • • We clarified the process we would follow to conduct the Care Plan Domain Analysis We identified the storyboards required to cover the range of situations to be covered in the DAM We developed / refined 2 storyboards Chronic care Home Care We discussed and modeled the dynamics of care plans We looked at and compared the contents of some care plans: Sweden, IHE, NEHTA, Nursing We started drafting requirements Page 16
• •
STORYBOARD REVIEW
Chronic Care Home Care Page 17
List of Required Care Plan Storyboards
• • • • • • Chronic Care Acute Care Home Care Perinatology Pediatric and Allergy/Intolerance Stay healthy/ health promotion • • Sources: IHE, CHI, HL7, etc.
This is the starter set. Is it sufficient?
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Guiding Principles for Storyboards
• • • • Describe a specific healthcare business problem (or processes) that require(s) the exchange of data/information By clinicians Need to ensure Readability Clinical accuracy, validity Coverage (focus on the 80%, not the exceptions) Refined as we progress in the DAM process Remember: storyboards get improved over time, as the project advances Page 19
SAMPLE OF DISCUSSIONS REGARDING CARE PLAN DAM
Page 20
Dynamic Federated Plan of Care Model provided by Laura
Page 21
Dynamic Federated Plan of Care Model provided by Laura- Discussion
• • • • This model illustrates a collaborative care model where the care plan is dynamically updated and maintained by multiple organizations and providers Referral is connected to the plan The pink line shows the flow when there is no federated care plan What is to be transmitted? The whole contents? Or the latest and most relevant data for the target organization/provider?
We need to look at a typical chronic disease case where multiple organizations are involved without a federated care plan and no common system Sweden is moving to a patient centric model with a central dynamic care plan with greater fluidity of information among providers Page 22
Discussion Notes
(Dynamic Plan of Care)
• ONC Transition of Care initiative Care Plan topic: exchange of information and knowledge Very time driven HIN 3 use cases: o o 2 approved: simple discharge, simple referral from primary care to specialist, Out for public comment: Discharged from hospital to nursing home/skilled nursing Page 23
Questions by Jay Lyle-
Post WGM-20110525
1.
2.
3.
Terminology I appreciate the distinction between the 'dynamic' and 'static' care plans, but I wonder if they might be better named as a “care plan application” and “care plan interoperability specification.” I think the HL7 spec will describe static documents or messages (interoperability specifications); I don't think it will provide functional requirements for applications.
20110608: these are different concepts, so no renaming “Federated” plan Is this intended to represent a government-mandated central care plan repository or application that other EHRs can use? In the US, that probably won't fly.
20110608: this is country/organization specific. It is conceptual model, agnostic to implementation System boundaries If System A and System B are applications, then there is only one interaction: communicate care plan (from A to B, or vice versa). If System A contains several applications (outpatient, inpatient, home, etc.), then there are many more interactions shown--each of which may have one or more use cases. In a SOA environment, those distinctions begin to blur, but we need to determine what processes (and constituent interactions, and, implicitly, system boundaries) the model should support.
20110608: noted.
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Candidate simplified context diagram,
Submitted by Jay Lyle, post-WGM, 20110525 Communications System Functional Care Plan System B 2. Exchange Plan 5. Alert User Interface 1. View Plan Functional Care Plan System A Care Plan Query / View System 2a. Synchronize Plan 3. Place Order 4. Get Observation Ancillary System (outpatient, inpatient, home, ED, etc.) 1.
2.
3.
4.
5.
View may support different sorts of queries, possibly for different sorts of clients (pink boxes in slide 19).
Exchange may support different levels of detail, or possibly a focus area Should ‘plans’ place orders ? Should they use existing HL7 order specifications? 20110608: NO Ditto #3 for observations System may alert provider based on plan, rule, and date or incoming observation.
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Types of care plans (provided by Stephen)
Created: 2011-03-09
• • Dynamic care plans Care plans that are developed, shared, actioned and revise realtime by participating care providers via a collaborative (likely to be web-based) care plan management environment supported by complex workflow management engine .
o o o o o o dynamic and organic coordinated by care coordinator (e.g. GP) shared realtime updated/managed realtime by all care provider can contain other care plans dynamic links to relevant patient information (where appropriate and feasible, i.e. privacy and security permit) and evidence-based resources Interchanged care plans Care plans that are shared (preferrably via electronic exchanges) and actioned by participating care providers o o o o o lack support of a realtime collaborative care plan management environment master care plan managed and updated/maintained mainly by a care coordinator (e.g. GP) with contributions from participating care providers interchanged care plan is essentially a snap shot of the master care plan at a point in time communicated often together with referral/request for services to target care providers can contain other care plans as attachments Page 26
Discussion Notes (Dynamic/Interchanged Care Plans)
• Charlie Bishop (2011-06-10) My notes and recall of the discussion are around the need for us to concentrate our efforts in the area that HL7 focuses on – i.e. the information and information structures related to Care Plans rather than the operational processes involved with the generation and use of Care Plans. It was this that brought the two Care Plan ‘definitions’ into the discussion: o o Dynamic Care Plans – updated and grow as patient care progresses and are updated and accessible to all carers linked to the patient at any point in time Interchanged Care Plan – static and communicated for continuity of care purposes It is the second of these that is of primary concern to our work in developing a small set of generic HL7 v3 information models that can be used to facilitate the many specialist care plan communication scenarios that are required in a multi-disciplinary care environment. HL7 v3 also has a ‘Dynamic’ component but this is not really concerned with how and why information is made available and persisted but how and why it is communicated/interchanged. There are clearly aspects of Dynamic Care Plans that are relevant to our understanding of the Interchanged Care Plans but this is primarily the information that is used rather than the processes that generate, access and use the information in a care setting.
Page 27
Notes by Sam missing
Discussion Notes
(Dynamic/Interchanged Care Plans)
• • Sam: he will send notes Susan: how is the information exchanged: real time?
VS CDA nested information On a selective basis Page 28
Care Plan – High Level Processes
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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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
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
Stephen Chu 12 April 2011
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
Detailed Care Plan
Page 30
Discussion Notes
(High Level Processes)
• • • • • • Versioning must be allowed Proposed and accepted Care Plans may be different o Required approval by care giver, patient o Implicit approval? Or explicit Key with static CPs Ensure that the patient is central to the process Vs provider centric Both approaches should be allowed?
Patient control? Preferences?
Financial responsibility implied?
NL mental health: central CP to individual CP Institution resources vs patient needs Each country has their process Patient care DMIM: can be author of CP Page 31
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 32
Ian McNicoll 2011-04-06
Ian McNicoll 2011-04-06
KEY RESOURCES FOR THE CARE PLAN DAM PROJECT
Page 35
Material and People
Material Source
Patient Care-DCM Patient Care-CP DSTU Patient care-Pressure Ulcer Care Statement Care Provision Structured Document CDA Templates Emergency care EHRS FM PHRS FM EHRS FM Profiles
People
To be filled
Notes
Page 36
Discussion Notes- Key Resources for the Care Plan DAM Project - 1
• • • DAM for devices DAM CIC CV (cardio-vascular) ISO CONSYS work: see brief descriptive summary on next slide ISO 13940 Health Informatics: System of concepts to support continuity of care aka ISO_TC215_N821_NWIP_13940_ContSys Page 37
What is ISO 13940 Health Informatics: System of concepts to support continuity of care?
• • • • • • • This ISO/TC215 Health informatics New Work Item Proposal (NWIP) N821 is intended to merge the previous work items 13940-1 System of concepts to support continuity of care Part 1 Basic concepts and Part 2 Healthcare process and workflow. This International Standard seeks to identify and define those processes which relate to co-operation between all parties involved in health care provided to human beings (to the exclusion of other living subjects). Given the definition of health as agreed by the World Health Organization (WHO), this International Standard will include those aspects of health care that rely on the acts of other actors than simply health care professionals. This International Standard specifically addresses aspects of sharing information related to a subject of care that is needed in the process of health care. This International multi-part standard addresses topics including: health care actors and other parties; organisational principles of health care, including co-operation between actors; health issues, health conditions and their management; time-related concepts like contacts, encounters, episodes of care and periods of care; concepts related to process, workflow and activities; concepts related to decision support, use of clinical knowledge and quality; concepts related to responsibility and information flows within the clinical process, like health mandates and their notification; concepts related to health data management. Whenever continuity of health care delivery implies social care activities as part of, or in support to, the process towards health recovery, these are to be mentioned wherever relevant in the process and workflow. In order to establish a common conceptual framework for continuity of care across national, cultural and professional barriers, all of these concepts are defined in this document, and their inter-relationships identified.
Note: this was prepared by Canada Health Infoway at ballot time.
Page 38
Discussion Notes- Key Resources for the Care Plan DAM Project - 2
• Danish washing machine project http://www.openecg.net/WS1_slides/S3_3_kvrneland/S3_arne.pdf
See next 2 slides Page 39
Extracts: National IT-strategy in the Danish Health Care System, Arne Kverneland, MD, National Board of Health
• Link various patient contacts around one episode of care Page 40
Extracts: National IT-strategy in the Danish Health Care System, Arne Kverneland, MD, National Board of Health
• Where care plans fit Page 41
Discussion Notes- Key Resources for the Care Plan DAM Project - 3
• In the EHR-S FM and the PHR-S FM there are functionalities about the care plan. Maybe its helpful to have a look at it, because it says something about the behavior of the system See summary model prepared by Anneke, next 3 slides This is based on R1.1 version We need to look at the draft R2 material (see HL7 EHR WG) Page 42
HL7/ISO EHR-S FM R1.1 Care Plan Elements: Direct Care 1.6, Care Plans, Treatment Plans, Guidelines, and Protocols
• Statement and Description of 2 functions
Provided by Anneke Goossen
Page 43
HL7/ISO EHR-S FM R1.1 Care Plan Elements: Direct Care 1.6, Care Plans, Treatment Plans, Guidelines, and Protocols
• Conformance Criteria for DC 1.6.1- Present Guidelines and Protocols for Planning Care
Provided by Anneke Goossen
Page 44
HL7/ISO EHR-S FM R1.1 Care Plan Elements: Direct Care 1.6, Care Plans, Treatment Plans, Guidelines, and Protocols
• Conformance Criteria for DC 1.6.2- Manage Patient Specific Care and Treatment Plans
Provided by Anneke Goossen
Page 45
Discussion Notes- Key Resources for the Care Plan DAM Project - 4
• ISO standard for the Care Plan: definition, see Care Plan option 3 on the wiki PC Glossary http://wiki.hl7.org/index.php?title=Patient_Care_Glossary This definition may be updated by the current CONTSYS work underway Page 46
SUGGESTIONS AND CONCERNS
Page 47
Suggestions and Concerns
• Australia project Uses DSTU material Some issues: what are they? Specific functions and attributes DAM work is good Need clarification of static vs dynamic Page 48
CONCLUSION
Page 49
Concluding Notes
• • Reminder: Care Plan DAM weekly meetings Wednesday, 17h00 EDT, 1.5 to 2 hours = 11h00 PM in NL All are welcome See wiki below for phone number and webex.
HL7 Wiki: Patient Care WG/ Care Plan Initiative 2011 http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 Page 50