1. Care Plan (CP) Team Meeting Notes (As updated during meeting) André Boudreau (a.boudreau@boroan.ca) Laura Heermann Langford (Laura.Heermann@imail.org) 2011-04-06 (No. 8) HL7 Patient Care Work Group Note 1: see April 13 th preliminary agenda on slide 5. Note 2: see notes received by email on page 12 and new Appendix 1 on Health Concern (by Kevin)

2. Page 2 Participants- Meetg of 2011-04-06 p1 Nameemail Country YesNoNotes André Boudreau a.boudreau@boroan.ca CAYes Laura Heermann Langford Laura.Heermann@imail.org USYes Stephen Chu stephen.chu@nehta.gov.au AUYes Peter MacIsaac peter.macisaac@hp.com AUYes Adel Ghlamallah aghlamallah@infoway-inforoute.ca CAYes William Goossen wgoossen@results4care.nl NL Anneke Goossen agoossen@results4care.nl NL Ian Townsend ian.townend@nhs.net UK Rosemary Kennedy Rosemary.kennedy@jefferson.edu US Jay Lyle jaylyle@gmail.com US Margaret Dittloff mkd@cbord.com USYes Audrey Dickerson adickerson@himss.org US Ian McNicoll Ian.McNicoll@oceaninformatics.com UK Danny Probst Danny.Probst@imail.org USYes Kevin Coonan Kevin.coonan@gmail.com USYes Gordon Raup graup@comcast.net USYes.

3. Page 3 Participants- Meetg of 2011-04-06 p2 Nameemail Country YesNoNotes David Rowed david.rowed@gmail.com AU Charlie Bishop charlie.bishop@isofthealth.com UK Walter Suarez walter.g.suarez@kp.org US Peter Hendler Peter.Hendler@kp.org US Ray Simkus ray@wmt.ca CA Elayne Ayres EAyres@cc.nih.gov US Lloyd Mackenzie lloyd@lmckenzie.com CALM&A Consulting Ltd. Serafina Versaggi serafina.versaggi@gmail.com US Sasha Bojicic SBojicic@infoway-inforoute.ca CA Lead architect, Blueprint 2015, Canada Health Infoway Agnes Wong awong@infoway-inforoute.ca CA RN, BScN, MN, CHE. Clinical Adoption - Director, Professional Practice & Clinical Informatics, Canada Health Infoway Cindy Hollister chollister@infoway-inforoute.ca CA RN, BHSc(N), Clinical Adoption -Clinical Leader, Canada Health Infoway Valerie Leung vleung@infoway-inforoute.ca CA Pharmacist. Clinical Leader, Canada Health Infoway

4. Page 4 Agenda for April 6th Review of Stephen’s slides on processes, structure and principles Review of Care Plans comparison provided by Ian Review of IHE Patient Plan of Care by Jay Review of draft list/description of deliverables (André) Identify agenda items for WGM in Orlando  Who will be there?  We seem to have 1.5 hour Updated status on the wiki and uploaded documents Update from Danny on use cases Agenda for next meeting

5. Page 5 Agenda for April 13th Storyboard criteria (Laura, Stephen, Danny) [see slide 20] Care Plan elements from KP, Intermountain, etc. (Laura) Business requirements: summary of key aspects since February (André)  This will become eventually our first formal deliverable: tentative structure: o Business and clinical context, overall need o Definition of the topic (theme) o Stakeholders and needs o Overall description of processes: contents dynamic, interchange: integrate Laura’s and Stephen’s models o Interrelationships with other processes (context diagram) o Scope (in and out) o Business objectives and outcomes o Vision Statement Introduction to Eclipse Workbench (Kevin): download and quick start Updated high level processes (Stephen) [done] IHE Patient Plan of Care (PPOC)?

6. Page 6 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

7. Page 7 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

8. Page 8 Care Plan – Process-based Structure 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 Diagnosis/problem/issue - primary - secondary … Problem/issue/risk/reason Desired goal/outcome Outcome target date 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 Review outcome Review recommendation/decision 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 Need to decide what tool to use for the next version

9. Page 9 Care Plan – Process-based Structure 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 Problem/issue/risk/reason Desired goal/outcome Outcome target date 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 Review outcome Review recommendation/decision Care orchestration Determine/plan appropriate interventions Determine/assign resources  healthcare providers  other resources Develop Plan of Care Refer to other provider (s) Problem/concern/reason 1..* Target goals/outcomes Planned intervention Assessed outcome High Level Shared Plan Care orchestration

10. Page 10 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

11. Page 11 Comparison of Care Plan Elements (Ian) See Xmind map: HL7 Care Plan- Models comparison- Sweden IHE NEHTA.xmind Sweden, IHE PCCP, NEHTA, IHE Nursing and aligned model Excellent work and tool Add a few more: find examples that are used a lot  KP?  VA?  Intermountain?  Mayo? Laura has direct contacts  Danny and Laura to add to the analysis

12. Page 12 IHE PCCP IHE (from March 23 rd ) Peter and Laura connected and reviewed what IHE did  Included AU work done Key documents: need to extract business requirements and principles  PCCP Patient Centered Coordination Plan (Ian- compare to Swedish) o Scoped back for the USA o Full version  Patient Plan of Care: for nursing (Jay)  eNursing summary (Peter and Stephen) Volume 1 and 2: IHE specific constructs: may not be useful Get ok from IHE that we can post on wiki: pdf versions? Some harmonization would be required May need to consider 2 architectures: one central dynamic CP, and a series of CP interconnected

13. Page 13 IHE Nursing plan of care Not adequate Incomplete See Jay’s deck IHE focus is on the exchange of documents, mainly HL7 CDA

14. Page 14 Notes sent by email- April 6th 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.

15. Page 15 Review of draft list/description of deliverables See wiki: HL7_PCWG_CarePlanDeliverables-Draft-20110405a.doc Business Requirements, Scope and Vision Standards context Storyboards and Use Cases Process Flow Domain Glossary Information Model Business triggers and Rules Harmonization (should be in parallel to produce the above to minimize rework) Interaction diagram Diagram of health concerns/problems and care plan on a timeline?  State machine diagram applied to concerns?? Lifecycle? Status of acts, referrals  Continuity of care timeline

16. Page 16 Tools that we will use Word Excel Power Point HL7 Eclipse (Open source), very powerful and MDA  Who will guide us: Kevin Select tool that XML open source No: Enterprise Architect (for all models) ? Xmind (for brainstorm?)  Can export to FreeMind Are there standard templates somewhere for Word, Excel? Or do we create our own?

17. Page 17 Agenda for Orlando WGMs Time available for care plan:  Thursday, Q1  May have a bit more time (allergy Q)  Add Q5 on one or more days Who is attending?  André, Laura, Kevin, Margaret, Stephen?, William  Unlikely: Peter, Adel Our focus?  TBD

18. Page 18 Notes on restructured wiki page Add team members that are regulars. Include profile notes.

19. Page 19 Danny’s work on story boards (from March 23 rd ) 4 areas of hi priorities  Perinatalogy  Chronic illness  Home health  Acute Trying to make them similar Allergies and intolerance: is this relevant to us?  Add a complicated scenario: primary care treatment plus a referral (Ian)  Stephen: [17:50:18] Stephen Chu: allergy and intolerance can produce a care plan of its own, e.g. coeliac disease, but I agree that we can embed it in all other care plans It would be useful to have a long term use case: see COPD We need to separate the clinical contents from the infrastructure that manages the care activities Not sure that we would want to build a composite use case but we should be able to abstract principles and requirements common to all [17:54:53] Stephen Chu: the content details will vary, but the structure should remain constant we need to differentiate the concepts - contents vs structure Lots of variety on different documents Have a matrix of what exists? Need an agreed way of producing storyboard: what are we trying to get out of it (Stephen and Laura)

20. Page 20 Storyboard: what is it? 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 Stephen Chu 12 April 2011

21. Page 21 DRAFT- Scope of 2011 Care Plan Initiative In scope Range of situations: curative, emergency, rehabilitation, mental health, social care, preventative, stay healthy, etc. Business /clinical needs around care planning: dynamics of creating, updating and communication care plans; functional perspective; dynamics; data exchange Out of scope Patient information complementary to the care plan: demographics, diagnostic, allergies and AR,

22. Page 22 Action Items as of 2011-04-06 No.Action ItemsBy Whom For When Status 2.Do an inventory of use cases and storyboard on hand Laura (Danny) Active: Underway 3.Ask William for an update (add in a diff colour to the appropriate pages)André Outstanding - Request made 5 Obtain and share the published version of the CEN Continuity of care P1 and P2; obtain ok from ISO Audrey/LauraOutstanding 7Update new wiki page with previous meeting material. Adjust structure of wiki.AndréWiki restructured 8Draft list of deliverables for this phaseAndréDraft prepared 9Draft a new PSS and review with project groupAndré 10 11 12 13 14 NB: Completed action items have been removed.

23. Page 23 APPENDIX 1- HEALTH CONCERN AND CARE PLANS

24. Page 24 Health concern and care plan: new paradigm to define the EHRS 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 pre-Guttenberg 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 From Kevin

25. Page 25 What We Know (information) and what we do (actions) 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! From Kevin

26. Page 26 CARE PLAN AND HEALTH CONCERN 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) fCare Plan: set of ongoing and future actions GOAL Health Concern Records what Happens From Kevin

27. Page 27 APPENDIX 2

28. 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:  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