Transcript Slide 1

See agenda for April 20th on slide 3.
Care Plan (CP) Team Meeting Notes
(As updated during meeting)
André Boudreau ([email protected])
Laura Heermann Langford ([email protected])
2011-04-13 (No. 9)
HL7 Patient Care Work Group
Agenda for April 13th
• Email notes from Kevin, Lloyd, William, Cecil
• Storyboard criteria (Laura, Stephen, Danny)
• Introduction to Eclipse Workbench (Kevin): download and
quick start
• Updated high level processes (Stephen)
• Issue: overarching term: condition, concern, problem?
Page 2
Agenda for April 20
•
•
•
•
•
•
•
Care Plan elements from KP, Intermountain, etc. (Laura)
Feedback on models prepared by Stephen (Laura and Susan)
Updated doc on storyboards (Danny)
IHE Patient Plan of Care (PPOC) (Ian)
Modeling tool to use (Eclipse or EA) (André)
Overarching term to use (Ian M.)
Business requirements: summary of key aspects since
February (André)

This will become eventually our first formal deliverable
• Next meeting agenda
Page 3
Participants- Meetg of 2011-04-13 p1
Name
email
Country
Yes
Notes
André Boudreau
[email protected]
CA
Yes
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
Yes
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
Yes
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
Adel Ghlamallah
[email protected]
CA
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
Yes
JP Systems. Informatics Consultant; Business Consultant & Sr. Project Manager
Margaret Dittloff
[email protected]
US
Yes
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
Ian McNicoll
[email protected]
UK
Yes
Ocean Informatics . Health informatics specialist; Formal general medical practitioner; OpenEHR;
Slovakia Pediatrics EMR; Sweden distributed care approach
Danny Probst
[email protected]
US
Yes
Intermountain Healthcare. Data Manager
Kevin Coonan
[email protected]
US
Gordon Raup
[email protected]
US
Yes
CTO, Datuit LLC (software industry).
Susan Campbell
[email protected]
US
Yes
PhD microbiologist. Specialist Master Consultant at Deloitte. HL7 Dynamic Care Plan Co-developer
Elayne Ayres
[email protected]
US
Yes
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
HP Enterprise Services. MD; Clinical Informatics Consultant; IHE Australia; Medical Practitioner General Practice
Yes
Canada Health Infoway. SME at Infoway (shared health record); past architect on EMR projects
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.
MD. Emergency medicine. HL7 Emergency care WG.
Page 4
Participants- Meetg of 2011-04-13 p2
Name
email
Country
Yes
No
Notes
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
Serafina Versaggi
[email protected]
US
Sasha Bojicic
[email protected]
CA
Lead architect, Blueprint
2015, Canada Health Infoway
LM&A Consulting Ltd.
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
Page 5
Notes sent by email- 2011-04-06
• Kevin Coonan



(1) The medication list is defined by the care plan. It is part of the therapy for a
given problem.
(2) The "problem list" is largely covered as well by the care plan. If you are getting
a specific therapy or plan for something, it is a problem (health concern!).
(3) We really need to determine which file formats are allowed. There are a lot of
tools, many of which overlap in what software can use it, so we should be able to
settle on some parsimonious set (mind map, outline, text files, information models,
UML, etc.).
• Lloyd McKenzie:

Usually "Medication List" refers to what meds a patient is on, not what the care plan
intends them to be on. The lists are often quite different. You may or may not have
a care plan for a given problem. But a patient's current problem list would be of
interest for all care plans.
Use these notes where applicable in our work.
Page 6
Email 1 from William 2011-04-07
• We have a hierarchy established and reconfirmed many times
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Guideline is the upper level framework
Which can be expressed as critical pathway
Which can be expressed in a care plan (Using the Care Plan R-MIM in Care Provision) for which we are now
creating the DAM.
Which can have order sets (e.g. a section taken from the guideline and expressed as part of a care plan, e.g.
a discharge planning set of activities).
Which can have any kind of list (e.g. using the Care Provision Statement Collector 1 to many times, e.g. one
statement collector for observation list, one SC for problem list, one for medication list, one for action plan,
one for outcome indicators, one for the discharge planning etc. Each SC can get a meaningful name. This
way the Care Plan R-MIM can on runtime have 100 Statement Collectors, each containing a million clinical
statements….!
Many many many individual care statements / clinical statements. Which is the bottom of the hierarchy
• Each Care Provision message can hold one or more of the above constructs 1-6. A Care
Provision message can have one clinical statement, or can have 7657543 clinical
statements, ordered with the above hierarchy, or as a flat series. Because most clinicians
want some order we have the organizer to link some clinical statements that belong
together, the statement collector to group a series of similar clinical statements and the
care plan for obvious reasons to reflect practice. The guideline is more the input of
knowledge to this.
• Response from Cecil Lynch

This is not a taxonomic hierarchy but rather relationships among artifacts. Please evaluate each of these
levels as an IS A statement and that will help you establish a hierarchy that is accurate.
First 3 bullets not HL7 specific. Pathway is organizational specific.
Page 7
Email 2 from William 2011-04-07
• This is part of the current Normative Edition, in particular the R-MIMs and D-MIM I refer
to and their explanation.
• The order I suggested is not really a taxonomy as Cecil suggests, it is not completely
representable in a ‘IsA’ relationship approach, it just a matter of organizing it in our
heads as what is available and how is it related to each other. That part of organizing it
has been discussed on several O&O and CDS and PC joint meetings of the past 3-4 years.
Always on Monday Q4 meetings, where O&O has the minutes. I agree it needs to be
documented and the wiki is a much better place for this. Let me do that during the WGM
CP meeting. I will be there and listen.
• Care Statements can be organized according to the Organizer Class, according to
Statement Collector(s), according to Care Plan so that is a bottom up relationship.
• Top down it can be as:
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Organizer class is a collection of 1-n different clinical statements that are usually grouped together.
Assessment scale representation is a specific organizer of clinical statements that are collected and
exchanged together because they are stated on the same date / time.
Statement collector is a collection of 1-n the same or similar clinical statements that are usually
stated on different dates and times
Care Care plan is a collection of several organizer classes representing 1-n clinical statements and /
or a collection of statement collectors, and/or a collection of individual clinical statements and or
other organizations of clinical statements (that is part of our current DAM work, to explore other
means).
Care Record R-MIM is a collection of clinical statements and/or a collection of clinical statements,
such as organized care statements, care statements in statement collector(s), and/or care plan(s),
and/or other collections further expressed in the R-MIM collection of the domain.
Use these notes where applicable in our work.
Page 8
Storyboard criteria
• See Danny’s document as annotated during the discussion
• See next slide with Stephen’s input
• Need to align with HDF 1.5 as this was decided in a previous
meetings
 See pages 27-28 and Appendix 1 of Power Point deck of 2011-0302 meeting
• Danny will update his document and resubmit for discussion
• Post meeting comment by André: suggest that the above
document be restricted to Storyboards for now, since we
already have the HDF 1.5 methodology document plus another
document listing our deliverables for this phase
Page 9
Storyboard: what is it?
Stephen Chu
12 April 2011
• Narrative of business (clinical; administrative)
processes on domain/area of interest
• Non technical (conceptual in nature)
• Describes:
• Activities, interactions, workflows
• Participants
• High level data contents feeding into or resulting from
processes
• Provides inputs for:
•
•
•
•
Activity diagrams
Interaction diagrams
State transition diagrams
High level class diagrams
Page 10
Care Plan Elements from KP, Intermountain, etc.
• Request wss sent out by Laura
• Some initial feedback, better to wait next week
Page 11
Introduction to Eclipse Workbench
• We need to agree on a tool to do:
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Use cases
Activity and workflow diagrams
Interaction diagrams
Class models
• Eclipse is a platform for doing many different things using
specific plug-ins
 Recommended by HL7
 Open Source but not as intuitive as Enterprise Architect (which
costs some 100$ for a desktop version)
• Ask publishing committee
• If Eclipse, we need some coaching to download and quick start
Eclipse
 Add plug-in for UML
 Adel agreed to help us there
Page 12
CARE PLAN – HIGH LEVEL PROCESSES
Page 13
Care Plan – High Level Processes
From April 6th
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
Page 14
IHE has more loose connections. Here assumes workflow engine that connects tightly problem, goal, task.
Need distinct process to manage/communicate/update/track/close the Care Plan. See IHE. Make more explicit here.
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
April 13
This is illustrative
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
Need to study this more:
Laura and Susan to work on it
Close problem/issues/reason/care plan
Page 15
Need to decide what tool to use for the next version
Care Plan – Process-based Structure
From April 6th
Initial Assessment
Identify problems/issues/reasons
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
Assess impact/severity:
 referral
 order tests
Diagnosis/problem/issue
- primary
- secondary …
Determine Problems & Outcomes
Problem/issue/risk/reason
Confirm/finalize problem/issue/reason list
Desired goal/outcome
Outcome target date
Determine goals/intended outcomes
Need a master plan with
linkages to sub-plans
Same as the problem list
2 levels: global that everyone
Can see: what by whom. Then a detail
Set outcome target date
Develop Plan of Care
Determine/plan appropriate interventions
Determine/assign resources
 healthcare providers
 other resources
Care Plan Implementation
Implement interventions
Planned intervention/care service
Planned intervention datetime/time interval
(including referrals)
links to other care plan as service plan
Responsible healthcare & other provider(s)
Intervention review datetime
Responsible review party/parties
Care Plan
Evaluation
Evaluate patient outcome
Review interventions
Follow-up Actions
Review outcome
Document outcomes
Revise/modify interventions
Review recommendation/decision
OR
Stephen Chu
5 April 2011
Close problem/issues/reason/care plan
Page 16
Will need to add explanations and maybe some different scenarios
Care Plan – Process-based Structure
Initial Assessment
Care orchestration
Identify problems/issues/reasons
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
Assess impact/severity:
 referral
 order tests
Determine Problems & Outcomes
High Level Shared Plan
Problem/concern/reason 1..*
Target goals/outcomes
Planned intervention
Assessed outcome
Confirm/finalize problem/concern/reason list
Determine goals/intended outcomes
Set outcome target date
Problem/issue/risk/reason
Desired goal/outcome
Outcome target date
Develop Plan of Care
Determine/plan appropriate interventions
Care
orchestration
Refer to other provider (s)
Determine/assign resources
Planned intervention/care service
Planned intervention datetime/time interval
(including referrals)
links to other care plan as service plan
Responsible healthcare & other provider(s)
 healthcare providers
 other resources
Care Plan Implementation
Implement interventions
Evaluation
Care Plan
Intervention review datetime
Responsible review party/parties
Evaluate patient outcome
Review interventions
Follow-up Actions
Document outcomes
Review outcome
Revise/modify interventions
OR
Stephen Chu
12 April 2011
Review recommendation/decision
Close problem/issues/reason/care plan
Page 17
ISSUE: WHAT OVERARCHING TERM TO
USE?
• Condition
• Health concern and care Plans
Page 18
Issues
• What overarching term to use?
 Condition: favoured by Care Provision: more neutral than ‘concern’
 Concern: allows for broader set of contexts for care planning, including
health maintenance activities
 Problem: focus on ‘wrong’ things; not well applicable to pregnancy: NO
 Health status: ‘current’ is not a term used
 Health issue: many people use it. Europe uses it (e.g. Sweden)
 See terms proposed (Susan)
 Synonyms: issue, concern
 We need to choose, define it and map it to existing terms
 Wait for our storyboards and map the correct word to each
 Build on existing term work done by reliable sources: HL7 Care Provision,
ISO/CEN concepts (Continuity of Care)
 Existing glossaries: HL7, CCMC (case management assoc), NLM
 Retain meaning of natural language where possible
 Use reliable sources
 Ian: he has done a term analysis
• Note: None of these terms are in the HL7 Core Glossary. See

http://www.hl7.org/v3ballot/html/welcome/environment/index.html
Page 19
‘Condition’ vs ‘Problem’: From Care Provision
(Jan 2011)
• …the term “Condition” is used generally in HL7 because it is less
negative than “problem,” i.e. management of normal pregnancy or
wellness is not considered management of a “problem.” In addition,
assessing and optimizing the condition of a patient is considered
central to effective healthcare by clinicians. Much of the following is
shared by the generalized discussions under Condition List and
Condition Tracking. Additional guidance on the use of the Condition
List and Condition Tracking structures in the specific use cases of
allergy and intolerance is given following the general discussions
below.
Source: ExplanationandGuidance.pdf document in the Care provision package v3_careprovision_2011JAN.zip Page 20
Health concern and care plan:
new paradigm to define the EHRS
From Kevin
• Historically, the EHR was similar to the GHR (Guttenberg Health
Record) that was systematically adhered to as it had since Sir.
William Osler told us how to treat patients. Often it is even preGuttenberg technology dependant (hand written).
• This paradigm was implemented in EHRS: PMH, CC, Social Hx, HPI,
etc. etc.
• This paradigm was somewhat impacted in the 1960’s by crazy Dr.
Larry Weed
• Every 50 years we need to re-think how we think of patients.
• We use information and generate information and actions.
 Information used is typically current problems/medications, HPI, and
ROS/PE.
 Actions are surgery, medical therapy, psychotherapy
 We translate what we know into what we do. This defines us and our
profession.
 So lets formalize it in a model which is optimized to support this
Page 21
What We Know (information) and
what we do (actions)
From Kevin
• A Health Concern can be linked to any relevant data: labs,
encounters, medications, care plan
 A Health Concern POV looks like a long hall way, with doors to
rooms with all kinds of crap in them. You can, if you read the
door name (aka Observaiton.code) query for all of the relevant
data (and graph it is numeric, etc.).
 At any given instant, what we know is effectively what is in the
health concern, and the H&P/initial nursing assessment.
 At a given point we have enough information to take action. This
action is captured in the Care Plan. Diagnosis or identified
problems/concerns then get updated.
 For every plan of care there better be some health concern!
Page 22
From Kevin
CARE PLAN AND HEALTH CONCERN
Health Concern
Records what Happens
fCare Plan: set of ongoing and future actions
GOAL
• Care plans need goals, i.e. tries to cause some
ObservationEvent to match it.
• Care plan has intimate relationship with HealthConcern—is
is the reason for the care plan
• Can view things via the HealthConcern POV, CarePlan
POV, the individual encounter POV, and Health Summary
(extraction/view)
Page 23
CONCLUSION
Page 24
Action Items as of 2011-04-13
No.
Action Items
By Whom
For
When
Status
Laura
(Danny)
Active: Underway
André
Outstanding - Request
made
Audrey/Laura
Outstanding
Update new wiki page with previous meeting material. Adjust structure of wiki.
André
Wiki restructured
8
Draft list of deliverables for this phase
André
Draft prepared
9
Draft a new PSS and review with project group
André
10
Initiate draft of requirements
André
2.
Do an inventory of use cases and storyboard on hand
3.
Ask William for an update (add in a diff colour to the appropriate pages)
5
Obtain and share the published version of the CEN Continuity of care P1 and P2;
obtain ok from ISO
7
11
12
13
14
NB: Completed action items have been removed.
Page 25
APPENDIX
Page 26
Review of draft list/description of
deliverables
• See wiki:
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2011-04-06
HL7_PCWG_CarePlanDeliverables-Draft-20110405a.doc
Business Requirements, Scope and Vision
Standards context
Storyboards and Use Cases
Interaction diagram
Process Flow
Domain Glossary
Information Model
Business triggers and Rules
• Diagram of health concerns/problems and care plan on a timeline?
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State machine diagram applied to concerns?? Lifecycle? Status of acts, referrals
Continuity of care timeline
• Harmonization (should be in parallel to produce the above to
minimize rework)
Page 27
Care Plan Development - Principles
2011-04-06
• 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 28
Definition of Care Plan on Wiki
• 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,
• Source: http://wiki.hl7.org/index.php?title=Care_Plan_Topic_project
Page 29