Transcript Slide 1

With meeting discussion notes
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Care Plan (CP) Meeting - Minutes
October 31, 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
Yes
Notes
Laura Heermann
Langford
[email protected]
US
x
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
x
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
Carolyn Silzle
[email protected]
US
American Dietetic Association
Susan Campbell
[email protected]
US
PhD microbiologist. Principal at Care Management Professionals. HL7 Dynamic Care Plan Co-developer
Kevin Coonan
[email protected]
US
MD. Emergency medicine. HL7 Emergency care WG.
Nancy Wilson Roman
US
Enrique Meneses
[email protected]
US
Serafina Versaggi
[email protected]
US
John Farmer
[email protected]
US
Chris White
[email protected]
US
Luigi Sison
[email protected]
US
x
Clinical Systems Consultant
x
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 31, 2012
(subject to change)
• Modelling update
• Clarifying “master care plan”/”care coordination
plan” – definitions
 Master care plan – domain specific detail care plan
relationship (Plan-plan compositions, that is, peer-peer or hierarchical connections between
CPs and/or between CP and POC)
• Inter-detail care plan relationship – inbound and
outbound risk
• Care plan concepts – terminology and definitions
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MODELING
• Enrique Meneses
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Discussion Notes
 Have worked on classes in EA extracted from the Storyboards
 Needs more work before reviews.
 Enrique and Jon will continue working in pairs offline. Jon could work on it
and propose reviewing in this larger group in 2 weeks (next meeting)
 Jon has also begun modeling a class diagram in EA describing relations
and how they would integrate into the model currently in progress.
 Enrique will work to set up a shared model repository for Jon to have
easier access to the model.
 Underlying files for the repository would be password protected.
 Need the corporate version EA to access.
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CARE PLAN RELATIONSHIPS (LINKED
OR NESTED…MASTER VS COORDINATED)
• Jon/Laura/Stephen…
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Discussion Notes

Have come to agreement there is an all over coordinating care plan… the Master Patient Care Plan.

Agreements
o
The master care plan is the specialty care plans interleaved. The service could be created to accommodate the
reconciliation
o
The concept of the patient or someone else being able to “hide” or “conceal” data from one care giver or provider or
another exists – but will be addressed later.
Examples of content that would need reconciliation--Meds, problems, history, allergies, advanced directives,
o

Discussions….
o
o
o
o
o
o
Care plan might inform the plan of care,
Plan of care = episodic plan
Master care plan and specialty care plan – both could inform the plan of care…
This is all very difficult to follow would be helpful to have a diagram. Perhaps – use a problem specific….such as
hypertension, or use one of the use cases we have developed – use the chronic care storyboard ….Laura to present
next time…
Terminology – to refer to Master Plan and the Specialty Plan that are really detailed but likewise relatively long term.
History of the plan and reports of activities from the plan are part of the medical record.

o
o

In the case of some observations – you may have the meta data on the care plan (blood pressure stead) instead of the last 14 readings…
Active goals stay on the care plan, resolved/completed goals become part of the medical record
Some goals, or medical issues may stay on the care plan even if they are complete or resolved…because they are
relevant to the overall care. Such as “smoked 4ppd for 30 years until last month…..”
Questionso
How much detail should be in the master care plan
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Discussion Notes
• Jon has taken extensive notes Laura to send her
notes to him for consolidation.
 5 November 2012 update: See next slides for consolidated
minutes
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Discussion Notes
Defining the master CP
Have come to agreement there is an overall coordinating care plan… the Master Patient Care Plan.
Example domain-specific CPs: Dental hygienist, Cardiologist
The master care plan is the specialty care plans interleaved. The service could be created to accommodate the
reconciliation
Master is high level coordinating care plan, shared among interdisciplinary providers that are specific to problem topic or
domain of practice.
A Coordination engine coordinates them.
Specialty plans don’t have to physically collected submitted to central storage, but can be federated , A CSS service, when
queried for the MCP of a particular patient, could deliver not only its local common root content, but it could also follow
pointers to the CSS interfaces of the specialty plans. Thus the MCP becomes virtually centralized for all its clients. This is
fully analogous to the full-continuum patient record, but it’s for the plans. Agreed in principal.
What Terminology to use? to refer to Master Plan and the Specialty Plan that are really detailed but likewise relatively long
term.
Master Plan will include its own content in addition to the specialty content, such as the Blood Glucose goals for a DM
patient.
Subsetting Views
The concept of the patient or someone else being able to “hide” or “conceal” data from one care giver or provider or another
exists – but will be addressed later.
Some elements only reside in master – like medication list. Also advance directives
Examples of content that would need reconciliation--Meds, problems, history, allergies, advanced directives,
Relevant fragments will be created among disjoint plans but can be reconciled into the MCP
Master is always inclusive of specialties., but user can filter views.
The CP subject matter scope is one thing (e.g. whether to include all or some specialties or a single specialty). Then there
could be different ways to sort it or present it – such as nested-plans, versus interleaved plan parts.
Discussions….
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Discussion Notes
Relationships of CP vs. POC
Care plan might inform the plan of care,
Plan of care = episodic plan
Master care plan and specialty care plan – both could inform the plan of care…
Then the POCs can update the master goals and progress, outcomes and recommendations, and procedural problems for
ongoing management.
Laura will prepare a graphic to illustrate.
SC: Perhaps – use a problem specific….such as hypertension, or use one of the use cases we have developed – use the
chronic care storyboard. MD or COPD, walk through to create diagram.
Keeping the MCP Lean
History of the plan and reports of activities from the plan are part of the medical record.
Optometry every 6 months – goes into master.
But … patient deteriorated. Laser treatment. Cataract has detailed cp to manage it. MCP does not need to know those
details.
MCP neds to know the visit times, that appointments were made. Procedure operation occurred, summary gets into the plan.
The “record” is not part fo the care plan. Anything that the opthalmologist considers “plan” should be considered part of the
care plan. When the two weeks pass, its part of the record, not the plan. Some believe that relevant history must be
retained to provide context. If goal is to stop smoking, is your goal to stop or to not smoke. The history helps to manage the
risk. So an observation can be designated for retention in plan.
In the case of some observations – you may have the meta data on the care plan (blood pressure steady) instead of the last
14 readings…
We need the goal and the outcome. Then from outcome might have meta observation – the observation about the
observation. Like 14 BPs daily over 7 days. These make a trend – a meta observation like “stabilized”
Perhaps this is the key to preventing the whole record from getting sucked into the CP.
CP audit trail would show effective-dated view of the Plan.
Goal of eye operation is to restore vision and …. No infection. No breakdown of cornea around incision. Strategy to ensure
that goals are achieved.
Active goals stay on the care plan, resolved/completed goals become part of the medical record
The MCP is prospective, so some content goes obsolete as time passes.
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Discussion Notes
Active
Guides future decisions
Some goals, or medical issues may stay on the care plan even if they are complete or resolved…because they are relevant
to the overall care. Such as “smoked 4ppd for 30 years until last month…..”
JF comment while editing: Meta-observations could be stored indefinitely (according to local policy or preference), but
merely filtered out by time window option for retrievals.
We may need to the ability to designate some items as permanent (perhaps there are a small number of alternative
“expiration policies” that a user could put on content)
QuestionsHow much detail should be in the master care plan
Assessments
Assessment is a process that is not part of the plan, but a process where the plan and the record come together.
Assessment is where you compare the status (which is in the record) to the goal (care plan). The info is met-goal.
That goal then stays on the plan? Some goals for chronic will be retained. Goal will then be to “maintain” BP at 120.
Milestone goals, Maintenance Goals
there will be long term (permanent) and short term goals. Return to full ambulation after surgery is a short term goals. BP
control is form now on.
SC: might state long term goal as normotensive.
Milestone goals are incremental or interim toward maintenance goal.
The goal issue is not unlike the problem list issue – resolved or inactive.
There are also wellness goals that are not equivalent to controlling BP. Then there are personal goals that you set for
yourself that may not fit into our previous categories of goals, e.g. healthy eating or periodic screening goals (colonoscopy
every five yrs); personal goals like I want to dance at my daughter
wedding.
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Next steps
• Next meeting
 Continue discussion on the care plan relationships, what is
included and not, definitions and terminology
o Laura to have diagram ready to generate and refine further
discussion
 Drill down to goals at some point in the diagram to demonstrate how
goals are added, updated, moved to medical record etc.
- Laura to bring goal work to next meeting
• Review modeling work as it is ready and needing
discussion.
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INBOUND/OUTBOUND RISKS
• Jon?…
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Discussion Notes
 Not yet addressed. Would like to get more of the previous discussion
completed before addressing the inbound/outbound risks
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CARE PLAN CONCEPTS: TERMINOLOGY
AND DEFINITIONS
• Laura
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Discussion Notes
 Not addressed specifically on the call today.
 Will be part of the continued discussion with the diagram next meeting
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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- November 14 (Lead:
Laura)
Upcoming Topics

.
• Future topic
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APPENDIX
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