Transcript Slide 1

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HL7 Care Plan (CP) Project
Care Coordination Services Project
Updates
May 2013 – Atlanta Meeting Updates
*Care Plan Project wiki:
http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012
* Care Coordination Project wiki:
http://wiki.hl7.org/index.php?title=Care_Coordination_Capabilities
Stephen Chu
Laura Heermann Langford
HL7 Patient Care Work Group
Overview of Progress
• Progress since Phoenix (January 2013 WGM)
• Care Plan DAM ballot delayed to Sept ballot cycle
 Continuous works
o Refinement of completed storyboards
o Care Plan structural and process models: stable
 http://wiki.hl7.org/index.php?title=Care_Plan
 Minor updates based on ONC/S&I collaborative discussions
o DAM main document: progressing
• Care coordination services functional model
 Informative ballot: May 2013 – on schedule
 Ballot comments from ONC/S&I tiger team
 Ballot reconciliation commenced and to continue after May WGM
 To be followed by OMG Technical Specification
• Collaboration with ONC/S&I
• Collaboration with Structured Doc WG – C-CDA IG: Care Plan
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Care Plan Structural Model (Conceptual)
http://wiki.hl7.org/index.php?title=Care_Plan
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Care Plan Structural Model (Conceptual)
Some definitions:
Care Plan, Plan Of Care
and Treatment Plan
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"The Care Plan represents the
synthesis and reconciliation of
the multiple plans of care
It serves as a blueprint shared
by all participants to guide the
individual’s care.
As such, it provides the
structure required to coordinate
care across multiple sites,
providers and episodes of care. "
Supports collaboration across
care settings and providers.
The "Care Plan and Plan of Care
share the universal components:
health concern, goals,
instructions, interventions, and
team member. “
• "A care plan integrates multiple interventions
proposed by multiple providers for multiple
conditions.” Includes relevant components
from multiple plans of care to provide a patient
centric, multi-disciplinary, comprehensive and
coordinated collaborative care.
• "A plan of care is proposed by an individual
clinician to address several conditions”. It
supports specialty specific plans.
• A Treatment Plan is specialty specific’
Developed to manage a specific condition.
The model below illustrates the use of inheritance
of shared features from an abstract Plan class.
• The “Plan” structure is
designed generic enough
to support: Care Plan,
Plan of Care and
Treatment Plan
•
-- Reference
S&I LONGITUDINAL COORDINATION OF CARE
WORK GROUP (LCCWG) Gloassary (v24)
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Care Plan Structural Model (Conceptual)
Plan Structure Overview
•
General Definition: A “list of
steps with timing and resources,
used to achieve an objective.
See also strategy. It is
commonly understood as a
temporal set of intended actions
through which one expects to
achieve a goal. “ Wikipedia
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Plan Types:
Care Plans, Plans of Care,
Treatment Plans
•
** The abstract plan is a modeling
convenience to represent shared
components.
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The Model Captures:
Who - Patient, Care Team,
Family, other Support
Individuals...
Why – Concerns, Risks and
Goals
What – Proposed and
Implemented Actions,
Outcomes Observations,
various types of Reviews
When - Effective times,
completion times, update times
Where –Steward organization,
place of service for
interventions
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Care Plan Structural Model
Descriptive Attributes
• displayName – descriptive display name for the plan
• clinicalSpecialty – specifies zero or more specialties
representing the topic of the plan.
• confidentiality – specifies the plan’s confidentiality level
Plan Attributes
• The Plan abstract class is
specialized by CarePlan,
PlanOfCare and
TreatmentPlan.
• The attributes are shared by
all subclasses of the Plan.
class Plan Attributes
Act
Plan
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+
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+
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+
+
achivementState :AchivementStateType
clinicalSpecialty :Code [1..*]
completeDate :DateTime
confidentiality :ConfidentialityType
createDate :DateTime
displayName :String
effectiveDate :DateTime
id :Identifier
latestUpdateDate :DateTime
planClass :PlanClassType
status :PlanStatus
version :String
A
State Attributes
• planStatus – plan stage lifecycle status
Temporal Attributes
• createDate – specifies when the plan was created
• effectiveDate – specifies the start of the plan
implementation
• completeDate – specifies when the plan becomes inactive
• lastUpdateDate – specifies the last date/time the plan
was changed
Information Management Attributes
• id – unique identifier for the plan
• version – change or difference indicator in the defining
plan elements (concern, goal, risk, proposed actions)

•
Implementation and tracking does not change the version
of the plan types
planClass – a class code (Care Plan, Plan of Care,
Treatment Plan)
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Care Plan Structural Model
Plan Participant Relationships
Patient, Provider, Caregiver
• Roles specify the plan’s interventional and observational action
participants
• Role relationships represent provider interaction paths and form the
patient’s care circle
• Relationships are key for a collaborative view of care coordination
(see HL7 CCS)
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Problems, Goals, Interventions and Risks
Diagnosis (e.g. Type 2 Diabetes Mellitus)
[a diagnosis often results in one or more problems for the patient]
[Primary] Problem 1: inability to regulate blood glucose level
Problem 2: urinary problems (resulting from hyperglycaemia)
[polyuria, nocturia]
Problem 3: polydipsia (resulting from excessive urine output)
Problem 4: weight loss (resulting from inability to process calorie from foods)
Problem 5: polyphagia (resulting from hunger effect of increased insulin output to process high blood glucose)
Problem 6: lethargy (resulting from inability to utilise glucose effectively)
Problem 7: altered mental state (resulting from hyperglycaemia, ketoacidosis, etc)
[agitation, unexplained irritability, inattention, or confusion]
Goal 1: maintain effective blood glucose control
[fasting = 4-6 mmol/litre]
Goal 2: maintain HbA1C level =< 7%
Intervention 1: diet control (diabetic diet)
Intervention 2: medications
Intervention 3: exercise (if overweight)
Outcome measures
daily BSL measures: pre-prandial reading 4-7mmol/l
post-prandial reading <8.5 mmol/l
HBA1C 3 monthly reading =<7%
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Intrinsic Risks: consequential to problem
Diagnosis (e.g. Type 2 Diabetes Mellitus)
[a diagnosis often results in one or more problems for the patient]
[Primary] Problem 1: inability to regulate blood glucose level
Problem 2: urinary problems (resulting from hyperglycaemia)
[polyuria, nocturia]
Problem 3: polydipsia (resulting from excessive urine output)
Problem 4: weight loss (resulting from inability to process calorie from foods)
Problem 5: polyphagia (resulting from hunger effect of increased insulin output to process high blood glucose)
Problem 6: lethargy (resulting from inability to utilise glucose effectively)
Problem 7: altered mental state (resulting from hyperglycaemia, ketoacidosis, etc)
[agitation, unexplained irritability, inattention, or confusion]
Risk 1: poor wound healing (resulting from impaired WBC, poor circulation from thickened blood vessels)
[high risk of foot/toe ulcers and gangrene] ← intrinsic risk (consequential to Type 2 DM)
Risk 2: increased infection (resulting from suppression of immune system from high glucose in tissues)
[skin, urinary tract] ← intrinsic risk
Risk 3: hyperlipidaemia ← intrinsic risk (can create outbound risks, e.g. increase CVS risks to those with family history)
Risk 4: microangiopathy ← intrinsic risk
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Extrinsic Risks: consequential to interventions
http://wiki.hl7.org/index.php?title=Presentations_on_Care_Plan_Projects_-_from_project_team_and_others
Diagnosis (e.g. Type 2 Diabetes Mellitus)
[a diagnosis often results in one or more problems for the patient]
[Primary] Problem 1: inability to regulate blood glucose level
Risk 1: poor wound healing (resulting from impaired WBC, poor circulation from thickened blood vessels)
[high risk of foot/toe ulcers and gangrene]
Risk 2: increased infection (resulting from suppression of immune system from high glucose in tissues)
[skin, urinary tract]
Risk 3: cardiovascular complications [e.g. hypertension, ischaemia heart disease]
Is outbound CVS risks affecting CVS care plan for same person with CVS comorbidity
(or increase CVS risk for those with positive family history of CVS problems)
Is an outbound risks affecting arthritis care plan for same person (esp when using cox-2 inhibitor analgesics
Risk 4: microangiopathy [e.g. retinopathy, nephropathy, peripheral neuropathy]
Is an outbound risks affecting renal infections management care plan of same person
(or when need to use aminoglycoside antibiotics to treat infections)
Risk 5: eye complications [e.g. cataract]
Is an outbound risks for patient with increased exposure to sunlights
[agriculture, forestry, fishing, construction industries]
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Care Plan Domain Analysis Model
• Project Plan with target for September Ballot
• Further discussion on glossary and relationships
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Care Plan Domain Analysis Model
Care Plan DAM Project Plan
17-Apr
1-May
15-May
29-May
12-Jun
26-Jun
10-Jul
24-Jul
7-Aug Aud 21
4-Sep
18-Sep
HL7 Deadlines for Ballot
Notification of Intent to Ballot due July 7
Initial Content Deadline (including topic and
artifact place holders) July 14th
Complete
NIB
Complete
Initial
Content
Preview for Ballot Opens (all material (even
draft) required for ballot July 21
Content and Reconciliation Deadlines (all
supporting V3 Content due. V2.7 final
content due. Recons completed. July 28
Ballot review period July 22-August 3
Ballot period August 12-September 16
HL7 Working Group Meeting September 2227
Complete
Final Content
Ballot Review 7/22-8/3
Ballot Period
HL7 WGM
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Care Plan Domain Analysis Model
Care Plan DAM Project Plan
17-Apr
1-May
15-May
29-May
12-Jun
26-Jun
10-Jul
24-Jul
7-Aug Aud 21
4-Sep
18-Sep
HL7 Deadlines for Ballot
Domain Analysis Model Deliverables
Buisiness Requirements, Scope and Vision
(2) Care plan can be essentially be
divided into three key constructs: (a)
clinical, demographic and
financial/administrative contents that
drives the care plan design and
implementation; (b) structure that
represents the structural components
of a care plan; (c) dynamic behaviours
that drive the care delivery and care
plan information activities
Standards Context
Storyboards/use Cases
Acute Care
Chronic Care
Home Care
Pediatric Allergy
Pediatric Immunization
Perinatology
Stay Healthy
Process Flow Diagram(s)
Domain Glossary
Business Process Model
Business Trigger Analysis
Business Rules
Information Model
Complete DAM Document write up
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Care Coordination Services (CCS)
• Co-sponsored by HL7 SOA, Patient Care, and Clinical
Decision Support work groups
• Part of Health Services Specification Program (HSSP)
 HL7 Service Functional Model (SFM) standard
 To be followed by OMG Technical Specification
The Care Coordination Service specification supports:
1. Dynamic care team collaboration and communication
2. Shared and up to date care plan and continuity of care
data required for effective coordination of care
3. Synchronized care team and patient information context
• Informative ballot: May 2013 ballot cycle
• Draft standard for trial use planned for September 2013
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CCS – Objectives
Enable flexible, controlled collaboration around a Dynamic and
Shared Care Plan with links to Continuity of Care Records
• Comprehensive, consolidated and synchronized Care Plan view
 Care team awareness, visibility and accountability of health concerns,
goals, activities
 The shared Care Plan is always up to date with changes from all
participants
 Synchronization updates and team communication facilitate reconciliation
and conflict resolution
• Flexible Collaboration
 Let care teams form organically based on invitations which respect existing
sharing agreements
• Establish links to supporting Continuity of Care records
 The plan triggers activities recorded in EHRs with provenance in distinct
organizations
 Activities and interventions captured in the continuity of care record can
trigger changes to the care plan
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CCS: Business Rules
These are general usage patterns with
multiple cross disciplinary uses
• Collaborative Contribution to an Integrated Care Plan
 Care Team Members work together to devise and maintain
the plan and its parts
• Sequential transitions of care
 Plan content gets lost on intake and discharge
• Iterative Plan Reviews and Revisions
 Constant iteration by any or all players
• Starting and Monitoring of Actions
Document:
http://wiki.hl7.org/index.php?title=Care_Coordination_Business_Scenarios
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CCS: Capabilities Summary
The capabilities express the functions CCS
supports:
• Care Team Membership and Collaboration
• Patient Assessment & Screening Process
• Care Planning and Execution Process
• Progress Tracking
• Team Reviews
Balloted Document at:
http://wiki.hl7.org/index.php?title=Care_Coordination_Capabilities
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Collaboration with ONC/S&I
• Members of HL7 Care Plan project working closely
with ONC/S&I
• Call between the teams on March 27 resulted in several
items of coordination.
• Review and analysis of Care Plan models, workflow
and CCS supports
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Care Plan Workflow
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Collaboration with ONC/S&I
Summary of conference call between HL7 Care Plan and ONC/S&I groups:
(1) There are terminology and definition alignment issues (within the health and health
informatics community) that need to be addressed urgently and effectively
(2) Care plan can be essentially be divided into three key constructs: (a) clinical,
demographic and financial/administrative contents that drives the care plan design and
implementation; (b) structure that represents the structural components of a care plan;
(c) dynamic behaviours that drive the care delivery and care plan exchange activities
(3) The uses cases developed by PCWG covers both the contents and behavioural
constructs. The use cases developed by LCC appear to cover the behavioural aspects
especially in relation to care plans exchange
(4) There are two broad categories of risks: (a) intrinsic risks that are related to a
person’s risk factors, barriers and their implications on health risks and health concerns;
(b) extrinsic risks that arise from the treatments or interventions that are planned and
implemented. Extrinsic risks are manifested as inbound and outbound risks in care plans
(5) Intrinsic risks (risk factors, barriers, health risks) and goals may be organised into
hierarchies
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Collaboration with ONC/S&I
Summary of conference call between HL7 Care Plan and ONC/S&I groups (continued):
(6) Intrinsic risks, goals, interventions and outcomes are related to each other in *..*
relationships
(7) There is definitive needs to rate/rank risks, prioritise goals and interventions
(8) Barriers can block interventions but not goals [I personally believe that barriers
while may not necessarily block goals, do often result in modification of goals]
(9) There are significant alignment between the thinking and design of ONC/LCC work
and HL7 Care plan work
(10) (a) There are also differences between work of the two groups. The plan is for the
differences to be clearly documented and for both groups to harmonize those areas of
differences before the September Care Plan DAM ballot
(b) review and refine care plan model
(11) ONC/LCC and HL7 Care plan group will organise conference calls to progress the
harmonization activities
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Collaboration with ONC/S&I
Summary of conference call between HL7 Care Plan and ONC/S&I groups (continued):
(12) HL7 Care Plan project team will work with Structure Doc on Care Plan CDA-IG
development with the aim of aligning the work of two groups.
(13) Review FHIR resources on Care Plan work and try to engage FHIR team to work
towards alignment
[One proposal: to identify a set of absolute minimum care plan components that are
required to support effective collaborative and continuity of care of the patient;
do a gaps analysis between the FHIR resources and the care plan minimal component
set determined by PCWG; work with FHIR team to address deficits in FHIR resources
on Care Plan]
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Summary of S&I Coordination Points
• 6 items related to Business Requirements, Scope
and Vision
• 1 item related to Storyboards
• 1 item related to Domain Glossary
• 1 item related to the information model
• 4 items related to logistics of coordination between
the teams.
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Summary of S&I Coordination Points
Care Plan DAM Project Plan
17-Apr
1-May
15-May
29-May
12-Jun
26-Jun
10-Jul
24-Jul
7-Aug Aud 21
4-Sep
18-Sep
HL7 Deadlines for Ballot
Coordination with S&I Framework
Team
(9) There are significant alignment between
the thinking and design of ONC/LCC work
and HL7 Care plan work
(10)There are also differences between work
of the two groups. The plan is for the
differences to be clearly documented and for
both groups to harmonize those areas of
differences before the September Care Plan
DAM ballot
(11)ONC/LCC and HL7 Care plan group will
organise conference calls to progress the
harmonization activities
(12)HL7 Care Plan project team will work
with Structure Doc on Care Plan CDA-IG
development with the aim of aligning the
work of two groups.
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Collaboration with ONC/S&I
Latest update from S&I Tiger Team:
• Define differences between Risks and Health Concerns,
map out how to categorize them
• Define Barriers, map out how to categorize them
• Define Goals, Concerns and Interventions, map out
how to designate prioritization of each
• Map out how to mitigate irrational choices (this
could fall under Risk discussion, as well)
• Map out how to assign Care Team Members to
prioritized Goals, Concerns and Interventions
• Patient priorities vs. Care Team Member priorities
• Align terminologies, definitions and Use Cases between
PCWG and LCC
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Collaboration with ONC/S&I
• Inputs from S&I will continue to help refine
 the Care Plan DAM leading up to September 2013
ballot
 the Care Coordination Services functional model
o Plan for DSTU ballot in September 2013
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Collaboration with Structured Document
• Structured Document work plan
 Produced C-CDA Implementation Guide for Care
Plan
 Patient Care WG co-sponsor
 PSS document being reviewed By PCWG and in
endorsement process
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Structured Document PSS
• This project will make various updates to Consolidated CDA,
including:
 Update the existing C-CDA Consult Note, create a Referral Note and
Transfer Summary incorporating data elements identified by ONC S&I LCC
community providers as high priority for the delivery of care when
transitioning a patient from one setting to another.
 Create a Care Plan document type, using existing C-CDA templates plus
new templates identified by ONC S&I LCC community providers aligned
with HL7 Patient Care WG’s Care Plan DAM.
 Incorporate identified errata.
 Update Meaningful Use Stage 2 templates (i.e. those C-CDA templates that
map to Meaningful Use Stage 2 data elements) based on latest guidance
decisions
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Structured Document PSS
• Project Need
 Existing Consolidated CDA (C-CDA) needs to be enhanced
by adding templates to represent high priority data
elements needed for transitions of care and care plans; we
need to incorporate errata; and we want to address areas
that implementers have found to be ambiguous.
• Project Objectives / Deliverables / Target Dates
 Define project scope May 2013
 Analysis, design and draft specifications (regular meetings) May – Sept
2013
 Submit notice of intent to ballot (NIB) July 7, 2013
 Submit for DSTU ballot Aug 2013
 Ballot period Sept 2013
 Ballot reconciliation Oct – Nov 2013
 Submit to TSC for DSTU approval and publication Dec 2013
 Subsequent ballots to be performed as needed Jan 2014
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FHIR
• Call with FHIR team held April 18
• Concerns expressed about minimal involvement from PCWG on
FHIR progress to date
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Future Meetings
• Conference calls between now and September 2013 – see
wiki
• 90 min., Wednesday 5-6:30pm US Eastern, fortnightly (every 2
weeks)
• Starting: to be determine (will start on May 15) (Quality team
members please join us on this call.)
• SOA CCS Meetings are on Tuesdays at 5-6:30 US Eastern (will
start on 22). This team meets every week.
Questions?
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Care Plan Project
• Call for collaboration and contributions from other
workgroups
• Care plan is a critically important tool to facilitate
effective coordinated care delivery
• If designed and implemented well, will make
significant contributions to health care
improvements
• Please participate and contribute
• Care Plan Project wiki:
http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012
• *Care Coordination Project wiki:
http://wiki.hl7.org/index.php?title=Care_Coordination_Capabilities
• Questions?
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