Transcript Slide 1

There are facilities for remote participation for those who cannot be in Orlando:
Teleconference: Call number: 770-657-9270, PIN 398644
Webex (thanks to Canada Health Infoway):
https://infoway-inforoute.webex.com/infoway-inforoute/j.php?ED=160071542&UID=494535562&RT=NCMxMQ%3D%3D
Care Plan (CP) Orlando WGM Meeting
(With meeting notes)
André Boudreau ([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 19th – Q1- 9h00 to 10h30
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Attendance and agenda check - 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)
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Participants- Meetg of 2011-05-19 p1
Name
email
Country
Yes
Notes
André Boudreau
[email protected]
CA
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
[email protected]
US
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
[email protected]
AU
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
Peter MacIsaac
[email protected]
AU
HP Enterprise Services. MD; Clinical Informatics Consultant; IHE Australia; Medical Practitioner General Practice
Adel Ghlamallah
[email protected]
CA
Canada Health Infoway. SME at Infoway (shared health record); past architect on EMR projects
William Goossen
[email protected]
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
[email protected]
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
[email protected]
UK
NHS Connecting for Health. Health Informatics; Senior Interoperability Developer, Data Standards and
Products; HL7 Patient Care Co-Chair
Rosemary Kennedy
[email protected]
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
[email protected]
US
JP Systems. Informatics Consultant; Business Consultant & Sr. Project Manager
Margaret Dittloff
[email protected]
US
The CBORD Group, Inc.. RD (Registered Dietitian); Product Manager, Nutrition Service Suite; HL7 DAM
project for diet/nutrition orders; American Dietetic Association
Audrey Dickerson
[email protected]
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
[email protected]
UK
Ocean Informatics . Health informatics specialist; Formal general medical practitioner; OpenEHR;
Slovakia Pediatrics EMR; Sweden distributed care approach
Danny Probst
[email protected]
US
Intermountain Healthcare. Data Manager
Kevin Coonan
[email protected]
US
MD. Emergency medicine. HL7 Emergency care WG.
Gordon Raup
[email protected]
US
CTO, Datuit LLC (software industry).
Susan Campbell
[email protected]
US
PhD microbiologist. Principal at Care Management Professionals. HL7 Dynamic Care Plan Co-developer
Elayne Ayres
[email protected]
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
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Participants- Meetg of 2011-05-19 p2
Name
email
Country
Notes
Yes
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
Lloyd Mackenzie
[email protected]
CA
LM&A Consulting Ltd.
Serafina Versaggi
[email protected]
US
Clinical Systems Consultant
Sasha Bojicic
[email protected]
CA
Lead architect, Blueprint 2015, Canada Health Infoway
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
US
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.
Luigi Sison
[email protected]
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BACKGROUND
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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
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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
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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)
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APPROACH AND DELIVERABLES
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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.
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Last updated: 2011-02-09
HDF- Domain Analysis Overview
act 3: Domain Analysis Ov erv iew
Business
Requirements
Source: HDF_1.5.doc, page 37
Project
Approved
Analyze Use
Cases
Analyze Business
Context
(from 3.4.2 Use Case Analysis)
«outcome»
(from 3.4.1 Business Context Analysis)
«outcome»
Use Case Analysis
Story board
(from 3.7 Artifacts)
(from 3.7 Artifacts)
Analyze Process Flow
(from 3.4.3 Process Analysis)
Process Flow
(from 3.7 Artifacts)
Glossary
Analyze Information Exchanged
(from 3.7 Artifacts)
(from 3.4.4 Information Analysis)
Information Model (Analysis)
(from 3.7 Artifacts)
Analyze Business Rules
«optional»
Business Rules Description
(from 3.4.5 Business Rules Analysis)
(from 3.7 Artifacts)
Business Trigger Analysis
(from 3.7 Artifacts)
Publish DAM
DAM Approv al
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Requirements Document- Structure
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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
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PROGRESS AND STATUS OF CP DAM
PROJECT
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Regular Participants at Weekly Meetings
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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
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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
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STORYBOARD REVIEW
• Chronic Care
• Home Care
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List of Required Care Plan Storyboards
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Chronic Care
Acute Care
Home Care
Perinatology
Pediatric and Allergy/Intolerance
Stay healthy
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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
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SAMPLE OF DISCUSSIONS
REGARDING CARE PLAN DAM
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Dynamic Federated Plan of Care Model provided
by Laura
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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
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Created: 2011-03-09
Types of care plans (provided by Stephen)
• 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 lack support of a realtime collaborative care plan management environment
o master care plan managed and updated/maintained mainly by a care coordinator
(e.g. GP) with contributions from participating care providers
o interchanged care plan is essentially a snap shot of the master care plan at a point
in time
o communicated often together with referral/request for services to target care
providers
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o can contain other care plans as attachments
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
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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
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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
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Sample of Structure and Contents (xmind models)
Ian McNicoll
2011-04-06
Sample of Structure and Contents (xmind models)
Ian McNicoll
2011-04-06
KEY RESOURCES FOR THE CARE PLAN
DAM PROJECT
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Material and People
Source
Material
People
Notes
Patient Care-DCM
Patient Care-CP DSTU
Patient care-Pressure
Ulcer
Care Statement
Care Provision
Structured Document
CDA
Templates
Emergency care
EHRS FM
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Discussion Notes- Key Resources for the Care
Plan DAM Project
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SUGGESTIONS AND CONCERNS
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Suggestions and Concerns
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CONCLUSION
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Concluding Notes
• Reminder: Care Plan DAM weekly meetings
 Wednesday, 17h00 EDT, 1.5 to 2 hours
 All are welcome
• HL7 Wiki: Patient Care WG/ Care Plan Initiative 2011
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