1. HL7 Care Plan (CP) Project Care Coordination Services Project Updates May 2013 – Atlanta Meeting Updates *C are 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 To join the meeting: Phone Number: +1 770-657-9270 Participant Passcode: 943377#

2. Page 2 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 Overview of Progress

3. Page 3 Care Plan Structural Model (Conceptual) http://wiki.hl7.org/index.php?title=Care_Plan

4. Page 4 Care Plan Structural Model (Conceptual) Some definitions: Care Plan, Plan Of Care and Treatment Plan "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 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. “ 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 )

5. Page 5 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 Wikipedia Plan Types: Care Plans, Plans of Care, Treatment Plans ** The abstract plan is a modeling convenience to represent shared components. 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

6. Page 6 Care Plan Structural Model Plan Attributes 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 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) The Plan abstract class is specialized by CarePlan, PlanOfCare and TreatmentPlan. The attributes are shared by all subclasses of the Plan.

7. Page 7 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)

8. Page 8 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 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] Problem 2: urinary problems (resulting from hyperglycaemia) [polyuria, nocturia] Problem 3: polydipsia (resulting from excessive urine output) 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%

9. Page 9 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 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 Problem 2: urinary problems (resulting from hyperglycaemia) [polyuria, nocturia] Problem 3: polydipsia (resulting from excessive urine output)

10. Page 10 Extrinsic Risks: consequential to interventions 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] Risk 4: microangiopathy [e.g. retinopathy, nephropathy, peripheral neuropathy] Risk 5: eye complications [e.g. cataract] 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 Is an outbound risks affecting renal infections management care plan of same person (or when need to use aminoglycoside antibiotics to treat infections) Is an outbound risks for patient with increased exposure to sunlights [agriculture, forestry, fishing, construction industries] http://wiki.hl7.org/index.php?title=Presentations_on_Care_Plan_Projects_-_from_project_team_and_others

11. Page 11 Care Plan Domain Analysis Model Project Plan with target for September Ballot Further discussion on glossary and relationships

12. Page 12 Care Plan Domain Analysis Model Care Plan DAM Project Plan 17-Apr1-May15-May29-May12-Jun26-Jun10-Jul24-Jul7-AugAud 214-Sep18-Sep HL7 Deadlines for Ballot Notification of Intent to Ballot due July 7 Complete NIB Initial Content Deadline (including topic and artifact place holders) July 14th 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 Complete Final Content Ballot review period July 22-August 3 Ballot Review 7/22-8/3 Ballot period August 12-September 16 Ballot Period HL7 Working Group Meeting September 22- 27 HL7 WGM

13. Page 13 Care Plan Domain Analysis Model Care Plan DAM Project Plan 17-Apr1-May15-May29-May12-Jun26-Jun10-Jul24-Jul7-AugAud 214-Sep18-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

14. Page 14 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

15. Page 15 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

16. Page 16 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 http://wiki.hl7.org/index.php?title=Care_Coordination_Business_Scenarios

17. Page 17 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

18. Page 18 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

19. Page 19 Care Plan Workflow

20. Page 20 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

21. Page 21 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

22. Page 22 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]

23. Page 23 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.

24. Page 24 Summary of S&I Coordination Points Care Plan DAM Project Plan 17-Apr1-May15-May29-May12-Jun26-Jun10-Jul24-Jul7-AugAud 214-Sep18-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.

25. Page 25 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

26. Page 26 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

27. Page 27 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

28. Page 28 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

29. Page 29 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 reconciliationOct – Nov 2013  Submit to TSC for DSTU approval and publication Dec 2013  Subsequent ballots to be performed as neededJan 2014

30. Page 30 FHIR Call with FHIR team held April 18 Concerns expressed about minimal involvement from PCWG on FHIR progress to date

31. Page 31 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?

32. Page 32 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 C are 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?