Transcript Slide 1

With meeting discussion notes
To join the meeting:
Phone Number: +1 770-657-9270
Participant Passcode: 943377#
Care Plan (CP) Meeting - Minutes
October 17, 2012
1700-1830 EDT
Laura Heermann Langford ([email protected])
Stephen Chu ([email protected])
*Care Plan wiki: http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011
HL7 Patient Care Work Group
ParticipantsName
email
Country
Laura Heermann
Langford
[email protected]
US
Stephen Chu
[email protected]
AU
Carolyn Silzle
[email protected]
US
Susan Campbell
[email protected]
US
Kevin Coonan
[email protected]
US
Nancy Wilson Roman
Yes
Co-Lead- Care Plan initiative/HL7 Patient Care WG. Intermountain Healthcare. RN PhD,: Nursing
Informatics; Emergency Informatics Association, American Medical Informatics Association; IHE
Y
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
American Dietetic Association
Y
PhD microbiologist. Principal at Care Management Professionals. HL7 Dynamic Care Plan Co-developer;
registered nurse specialist
MD. Emergency medicine. HL7 Emergency care WG.
US
Enrique Meneses
[email protected]
US
Serafina Versaggi
[email protected]
US
Jon Farmer
[email protected]
US
Chris White
[email protected]
US
Luigi Sison
[email protected]
US
Brett Esler
[email protected]
AU
Y
US
Y
Russ Leftwich
Notes
Y
Clinical Systems Consultant
Y
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.
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Tentative: October 17, 2012
(subject to change)
 Revamped Care Plan wiki
o http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012
o Contributions to story boards that include care services coordination scenarios
 http://wiki.hl7.org/index.php?title=Care_Plan_Storyboards_with_care_coordination_services
_scenarios
 Compare/contrast Case Manager and PCP Perspective – Jon Farmer
 Modeling –Enrique
o To review work in progress through wiki conversation
o Discuss and work out any “kinks” in the working process using the wiki for
discussion/updates etc.
o Continue with a synchronous working session on the model with Enrique
facilitating
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MODELING
• Enrique Meneses
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Discussion Notes
 Jon: CMSA “barrier” discussion
 Need - some real-world examples of barriers that case managers routinely
encounter in acute, EMS, or chronic settings
• Notes from last meeting

Review of Luigi’s model and decided need to more analysis concentrating on scope and the boundaries in addition
to the project scope discussion.

Next Steps
o
o
Document additional use cases as discussed earlier
Break Luigi’s model down for more discussion. Enrique will put it on the wiki page to facilitate more off line
conversation. Enrique will send out email notice when ready for review.
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Discussion Notes
 Jon: CMSA “barrier” discussion
 Need - some real-world examples of barriers that case managers routinely
encounter in acute, EMS, or chronic settings
 Draft document from Jon on modeling barriers
 Patient has medical/physiological problems or concerns
 Socio-economical and or psychological issues/problems may present
barriers for attainment of goals set and interventions planned to resolve
the medical/physiological problems
 Examples: absence of social support network; or lack of transport means
 Question: how should these barriers be modeled
o In paper care plans:
 These barriers are represented as problems or concerns independently
o In electronic care plans
 They need to be represented/modelled as co-dependencies between the barriers and
medical/physiological problems
 Action item:
o Jon Farmer to produce draft of 2-3 use cases and circulate to Laura, Stephen,
Russ, Kevin, etc for further inputs
o Use cases to be discussed at next meeting (31 october)
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Discussion Notes
 Enrique presented a spreadsheet that contains breakdown of storyboard
sentences into “subject-verb-object” predicates
 Spreadsheet contents form the basis for modelling work
 Screen shot of spreadsheet – see next slide
 Action item:
o Enrique to continue work on decomposition and population of spreadsheet
o Draft model to be circulated prior to next conference call
o Continue discussion at next conference call
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Care Plan storyboard decomposition
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Care Plan Discussions
 Similar and related concepts causing confusion:
o
o
o
o
o
Care Plan
Plan of Care
Master care plan
Clinical pathway
Critical pathway

Links included in Baltimore WGM meeting slide deck by Susan Campbell provide
useful information on some of these concepts

These links are in the next few slides extracted from the Susan Campbell slide deck
Page 9
From Susan Campbell slide deck
(Baltimore WGM September 2012)
1. LCC Use Case. Outlines three scenarios for health information
exchanges between: 1) an acute care hospital and home
health agency (HHA); 2) a skilled nursing facility (SNF) and the
Emergency Department (ED); and 3) a Physician and a HHA

Two of the scenarios center on the Home Health Plan of Care (HH-POC), based
off CMS 485 form. The HH-POC supports the HHA in providing patient service via
MD orders. The HHA and physician exchange information on patient’s evolving
condition and needs, and the services the HHA will perform.
2. LCC Whitepaper. Meaningful Use Requirements For:
Transitions of Care & Care Plans For Medically Complex and/or
Functionally Impaired Persons. Includes a robust discussion of
needs and issues regarding interoperable care plan
collaboration and exchange.

A summary is also available here.
3. Preliminary Stage 3 MU Recommendations. Provided for
July 16, 2012 meeting of Health IT Policy Committee
Meaningful Use Subworkgroup #3 (includes comments on
proposed Meaningful Use Stage 2 requirements related to care
plans)
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From Susan Campbell slide deck
(Baltimore WGM September 2012)
Definition,
content,
sections, and
standards of a
collaborative
care plan that
can support
care planning
for a variety of
patient types
over time –
interoperably.
An animated Powerpoint presentation of this LCC vision of longitudinal care planning
is available on the wiki here.
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From Susan Campbell slide deck
(Baltimore WGM September 2012)
Long Term and Post-Acute Care (LTPAC) Transitions of Care
SWG:
• Priority Transitions. Examined transitions to/from eleven providers
• IMPACT Project Data Elements List. Updated and merged LCC Use
Case 1.0 Data Elements
 Five transitions of care data sets, all subsets of the LCC Use Case
Data Elements. The permanent transfer of care contains the
entire set of data elements.
Patient Assessment Summary (PAS) SWG:
• Balloted Functional Status, Cognitive Status, & Pressure Ulcer
templates for Consolidated CDA (May 2012)
• Balloted Patient Questionnaire Assessment Summary
Implementation Guide for CDA Release 2 (September 2012)
• Mapped the MDS, OASIS, CARE Tool, Massachusetts Universal
Transfer Form (IMPACT Dataset #5 with 328 data elements), and
C83 data elements (prioritized by Beacon Community Affinity
Group). (link)
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• Meeting adjourned at 6:35pm US Eastern
• Next meeting:
Wednesday 31 October 2012 at 5:00pm US Eastern
Next Agenda
FUTURE MEETINGS
• Conference calls between now and January 2013 – see wiki
• 90 min., Wednesday 5-6:30pm US Eastern, fortnightly (every 2 weeks)
• Starting September 19
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Next meeting Agenda- October 31 (Lead:
tentative: Laura)
Meeting Agenda

To be announced
• Future topic
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APPENDIX
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