Presentation on theme: "Care Plan (CP) Orlando WGM Meeting (With meeting notes) André Boudreau Stephen Chu"— Presentation transcript:
Care Plan (CP) Orlando WGM Meeting (With meeting notes) André Boudreau (email@example.com)firstname.lastname@example.org Stephen Chu (mailto:email@example.com)mailto:firstname.lastname@example.org Laura Heermann Langford (Laura.Heermann@imail.org)Laura.Heermann@imail.org 2011-05-19, Q1, 9h00 to 10h30 Care Plan wiki: http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 HL7 Patient Care Work Group V4- With discussion notes verified and augmented as of 2011-06-10. Includes post WGM meeting comments by Jay Lyle on Dynamic Federated Plan of Care Model. Includes new slides for Danish model, ISO CONTSYS project, EHR-S FM R1.1 extracts for Care Plans. Slide 36 should be filled to ensure that we don’t miss reusable material and do not reinvent contents.
Page 2 Agenda - May 19 th – Q1- 9h00 to 10h30 Attendance and agenda check – Stephen/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)
Page 3 Participants- WGM Meetg of 2011-05-19 p1* Nameemail Country YesNotes André Boudreau email@example.com 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 Laura.Heermann@imail.org 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 firstname.lastname@example.org 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@example.com AU HP Enterprise Services. MD; Clinical Informatics Consultant; IHE Australia; Medical Practitioner - General Practice Adel Ghlamallah firstname.lastname@example.org CA Canada Health Infoway. SME at Infoway (shared health record); past architect on EMR projects William Goossen email@example.com NL Yes 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 firstname.lastname@example.org NL Yes 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@example.com UK NHS Connecting for Health. Health Informatics; Senior Interoperability Developer, Data Standards and Products; HL7 Patient Care Co-Chair Rosemary Kennedy Rosemary.firstname.lastname@example.org 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@example.com US JP Systems. Informatics Consultant; Business Consultant & Sr. Project Manager Margaret Dittloff firstname.lastname@example.org 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@example.com 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 Ian.McNicoll@oceaninformatics.com UK Ocean Informatics. Health informatics specialist; Formal general medical practitioner; OpenEHR; Slovakia Pediatrics EMR; Sweden distributed care approach Danny Probst Daniel.Probst@imail.org US Intermountain Healthcare. Data Manager Kevin Coonan Kevin.firstname.lastname@example.org US MD. Emergency medicine. HL7 Emergency care WG. Gordon Raup email@example.com US CTO, Datuit LLC (software industry). Susan Campbell firstname.lastname@example.org USYes PhD microbiologist. Principal at Care Management Professionals. HL7 Dynamic Care Plan Co-developer Elayne Ayres EAyres@cc.nih.gov 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 *: includes on site and teleconference participants
Page 4 Participants- WGM Meetg of 2011-05-19 p2* Nameemail Country Yes Notes David Rowed email@example.com AU Charlie Bishop firstname.lastname@example.org UK Yes Walter Suarez email@example.com US Peter Hendler Peter.Hendler@kp.org US Ray Simkus firstname.lastname@example.org CA Lloyd Mackenzie email@example.com CALM&A Consulting Ltd. Serafina Versaggi firstname.lastname@example.org US Clinical Systems Consultant Sasha Bojicic SBojicic@infoway-inforoute.ca CALead architect, Blueprint 2015, Canada Health Infoway Agnes Wong email@example.com CA RN, BScN, MN, CHE. Clinical Adoption - Director, Professional Practice & Clinical Informatics, Canada Health Infoway Cindy Hollister firstname.lastname@example.org CA RN, BHSc(N), Clinical Adoption -Clinical Leader, Canada Health Infoway Valerie Leung email@example.com CAPharmacist. Clinical Leader, Canada Health Infoway Luigi Sison firstname.lastname@example.org USYes 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. Brett Esler email@example.com AUYesPen Computer Sys Catherine Hoang firstname.lastname@example.org US YesVA Hugh Leslie email@example.com Yes Seam Heard firstname.lastname@example.org Yes *: includes on site and teleconference participants
Page 6 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
Page 7 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 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)
Page 8 Discussion Notes (Background) Focus on requirements Do not worry about RMIM for 2 years Issue Contents are derivation from RIM components, F class Should not find anything that is not covered in the RIM D-MIM is top o Informed by use cases o CP DAM is key to validate our DMIM Care Provision DMIM is key Clinical Statement will be used in the future: to be proven Copy what is useful from past work Plan Walkthrough of DSTU and other existing material at a future meeting by William (André/Laura to schedule) Patient Care WG has 18 projects
Page 10 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.
Page 12 Requirements Document- Structure 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
Page 13 Discussion Notes (Approach and Deliverables) Care Plan can be dynamic and also have static moments Important to be pragmatic to achieve results in reasonable time Coordination of care is the key Keep things simple otherwise we will be caught in a lot of complexity Understand context and stakeholders needs We will not focus on the process of developing care plan There are 100’s of ways of developing CPs But the interoperable info has to accommodate all this We are modeling only the info, not the process
Page 15 Regular Participants at Weekly Meetings 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
Page 16 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
Page 17 STORYBOARD REVIEW Chronic Care Home Care
Page 18 List of Required Care Plan Storyboards Chronic Care Acute Care Home Care Perinatology Pediatric and Allergy/Intolerance Stay healthy/ health promotion Sources: IHE, CHI, HL7, etc. This is the starter set. Is it sufficient?
Page 19 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
Page 20 SAMPLE OF DISCUSSIONS REGARDING CARE PLAN DAM
Page 21 Dynamic Federated Plan of Care Model provided by Laura
Page 22 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
Page 23 Discussion Notes (Dynamic Plan of Care) ONC Transition of Care initiative Care Plan topic: exchange of information and knowledge Very time driven HIN- 3 use cases: o 2 approved: simple discharge, simple referral from primary care to specialist, o Out for public comment: Discharged from hospital to nursing home/skilled nursing
Page 24 Questions by Jay Lyle- Post WGM-20110525 1.Terminology I appreciate the distinction between the 'dynamic' and 'static' care plans, but I wonder if they might be better named as a “care plan application” and “care plan interoperability specification.” I think the HL7 spec will describe static documents or messages (interoperability specifications); I don't think it will provide functional requirements for applications. 20110608: these are different concepts, so no renaming 2.“Federated” plan Is this intended to represent a government-mandated central care plan repository or application that other EHRs can use? In the US, that probably won't fly. 20110608: this is country/organization specific. It is conceptual model, agnostic to implementation 3.System boundaries If System A and System B are applications, then there is only one interaction: communicate care plan (from A to B, or vice versa). If System A contains several applications (outpatient, inpatient, home, etc.), then there are many more interactions shown--each of which may have one or more use cases. In a SOA environment, those distinctions begin to blur, but we need to determine what processes (and constituent interactions, and, implicitly, system boundaries) the model should support. 20110608: noted.
Page 25 Functional Care Plan System A Care Plan Query / View System Functional Care Plan System B Ancillary System (outpatient, inpatient, home, ED, etc.) 1. View Plan 2. Exchange Plan 3. Place Order 4. Get Observation 1.View may support different sorts of queries, possibly for different sorts of clients (pink boxes in slide 19). 2.Exchange may support different levels of detail, or possibly a focus area 3.Should ‘plans’ place orders? Should they use existing HL7 order specifications? 20110608: NO 4.Ditto #3 for observations 5.System may alert provider based on plan, rule, and date or incoming observation. Communications System 5. Alert User Interface 2a. Synchronize Plan Candidate simplified context diagram, Submitted by Jay Lyle, post-WGM, 20110525
Page 26 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 dynamic and organic o coordinated by care coordinator (e.g. GP) o shared realtime o updated/managed realtime by all care provider o can contain other care plans o 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 o can contain other care plans as attachments Created: 2011-03-09
Page 27 Discussion Notes (Dynamic/Interchanged Care Plans) Charlie Bishop (2011-06-10) My notes and recall of the discussion are around the need for us to concentrate our efforts in the area that HL7 focuses on – i.e. the information and information structures related to Care Plans rather than the operational processes involved with the generation and use of Care Plans. It was this that brought the two Care Plan ‘definitions’ into the discussion: o Dynamic Care Plans – updated and grow as patient care progresses and are updated and accessible to all carers linked to the patient at any point in time o Interchanged Care Plan – static and communicated for continuity of care purposes It is the second of these that is of primary concern to our work in developing a small set of generic HL7 v3 information models that can be used to facilitate the many specialist care plan communication scenarios that are required in a multi-disciplinary care environment. HL7 v3 also has a ‘Dynamic’ component but this is not really concerned with how and why information is made available and persisted but how and why it is communicated/interchanged. There are clearly aspects of Dynamic Care Plans that are relevant to our understanding of the Interchanged Care Plans but this is primarily the information that is used rather than the processes that generate, access and use the information in a care setting.
Page 28 Discussion Notes (Dynamic/Interchanged Care Plans) Sam: he will send notes Susan: how is the information exchanged: real time? VS CDA nested information On a selective basis Notes by Sam missing
Page 29 Care Plan – High Level Processes Stephen Chu 5 April 2011 Identify problems/issues/reasons Assess impact/severity: referral order tests Initial Assessment Confirm/finalize problem/issue/reason list Determine goals/intended outcomes Determine Problems & Outcomes Set outcome target date Determine/plan appropriate interventions Determine/assign resources healthcare providers other resources Develop Plan of Care Implement interventions Care Plan Implementation Evaluate patient outcome Review interventions Evaluation Document outcomes Revise/modify interventions OR Close problem/issues/reason/care plan Follow-up Actions 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 Care Plan This is based on a broad review. All converge. 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 Add care coordination activities in these activities Need a concept of a master care plan with all the concerns and problems
Page 30 Care Plan – High Level Processes Stephen Chu 12 April 2011 Identify problems/issues/reasons Assess impact/severity: referral order tests Initial Assessment Confirm/finalize problem/concern/reason list Determine goals/intended outcomes Determine Problems & Outcomes Set outcome target date Implement interventions Care Plan Implementation Evaluate patient outcome Review interventions Evaluation Document outcomes Revise/modify interventions OR Close problem/issues/reason/care plan Follow-up Actions 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 Care Plan Care orchestration Problem/concern/reason 1..* Target goals/outcomes Planned intervention Assessed outcome High Level Shared Plan Detailed Care Plan Determine/plan appropriate interventions Determine/assign resources healthcare providers other resources Develop Plan of Care Refer to other provider (s) Care orchestration
Page 31 Discussion Notes (High Level Processes) Versioning must be allowed Proposed and accepted Care Plans may be different o Required approval by care giver, patient o Implicit approval? Or explicit Key with static CPs Ensure that the patient is central to the process Vs provider centric Both approaches should be allowed? Patient control? Preferences? Financial responsibility implied? NL mental health: central CP to individual CP Institution resources vs patient needs Each country has their process Patient care DMIM: can be author of CP
Page 32 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
Sample of Structure and Contents (xmind models) Ian McNicoll 2011-04-06
Sample of Structure and Contents (xmind models) Ian McNicoll 2011-04-06
Page 35 KEY RESOURCES FOR THE CARE PLAN DAM PROJECT
Page 36 Material and People SourceMaterialPeopleNotes Patient Care-DCM Patient Care-CP DSTU Patient care-Pressure Ulcer Care Statement Care Provision Structured Document CDA Templates Emergency care EHRS FM PHRS FM EHRS FM Profiles To be filled
Page 37 Discussion Notes- Key Resources for the Care Plan DAM Project - 1 DAM for devices DAM CIC CV (cardio-vascular) ISO CONSYS work: see brief descriptive summary on next slide ISO 13940 Health Informatics: System of concepts to support continuity of care aka ISO_TC215_N821_NWIP_13940_ContSys
Page 38 What is ISO 13940 Health Informatics: System of concepts to support continuity of care? This ISO/TC215 Health informatics New Work Item Proposal (NWIP) N821 is intended to merge the previous work items 13940-1 System of concepts to support continuity of care Part 1 Basic concepts and Part 2 Healthcare process and workflow. This International Standard seeks to identify and define those processes which relate to co-operation between all parties involved in health care provided to human beings (to the exclusion of other living subjects). Given the definition of health as agreed by the World Health Organization (WHO), this International Standard will include those aspects of health care that rely on the acts of other actors than simply health care professionals. This International Standard specifically addresses aspects of sharing information related to a subject of care that is needed in the process of health care. This International multi-part standard addresses topics including: health care actors and other parties; organisational principles of health care, including co-operation between actors; health issues, health conditions and their management; time-related concepts like contacts, encounters, episodes of care and periods of care; concepts related to process, workflow and activities; concepts related to decision support, use of clinical knowledge and quality; concepts related to responsibility and information flows within the clinical process, like health mandates and their notification; concepts related to health data management. Whenever continuity of health care delivery implies social care activities as part of, or in support to, the process towards health recovery, these are to be mentioned wherever relevant in the process and workflow. In order to establish a common conceptual framework for continuity of care across national, cultural and professional barriers, all of these concepts are defined in this document, and their inter-relationships identified. Note: this was prepared by Canada Health Infoway at ballot time.
Page 39 Discussion Notes- Key Resources for the Care Plan DAM Project - 2 Danish washing machine project http://www.openecg.net/WS1_slides/S3_3_kvrneland/S3_arne.pdf http://www.openecg.net/WS1_slides/S3_3_kvrneland/S3_arne.pdf See next 2 slides
Page 40 Extracts: National IT-strategy in the Danish Health Care System, Arne Kverneland, MD, National Board of Health Link various patient contacts around one episode of care
Page 41 Extracts: National IT-strategy in the Danish Health Care System, Arne Kverneland, MD, National Board of Health Where care plans fit
Page 42 Discussion Notes- Key Resources for the Care Plan DAM Project - 3 In the EHR-S FM and the PHR-S FM there are functionalities about the care plan. Maybe its helpful to have a look at it, because it says something about the behavior of the system See summary model prepared by Anneke, next 3 slides This is based on R1.1 version We need to look at the draft R2 material (see HL7 EHR WG)
Page 43 HL7/ISO EHR-S FM R1.1 Care Plan Elements: Direct Care 1.6, Care Plans, Treatment Plans, Guidelines, and Protocols Statement and Description of 2 functions Provided by Anneke Goossen
Page 44 HL7/ISO EHR-S FM R1.1 Care Plan Elements: Direct Care 1.6, Care Plans, Treatment Plans, Guidelines, and Protocols Conformance Criteria for DC 1.6.1- Present Guidelines and Protocols for Planning Care Provided by Anneke Goossen
Page 45 HL7/ISO EHR-S FM R1.1 Care Plan Elements: Direct Care 1.6, Care Plans, Treatment Plans, Guidelines, and Protocols Conformance Criteria for DC 1.6.2- Manage Patient Specific Care and Treatment Plans Provided by Anneke Goossen
Page 46 Discussion Notes- Key Resources for the Care Plan DAM Project - 4 ISO standard for the Care Plan: definition, see Care Plan- option 3 on the wiki PC Glossary http://wiki.hl7.org/index.php?title=Patient_Care_Glossary http://wiki.hl7.org/index.php?title=Patient_Care_Glossary This definition may be updated by the current CONTSYS work underway
Page 50 Concluding Notes Reminder: Care Plan DAM weekly meetings Wednesday, 17h00 EDT, 1.5 to 2 hours = 11h00 PM in NL All are welcome See wiki below for phone number and webex. HL7 Wiki: Patient Care WG/ Care Plan Initiative 2011 http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011