Care Plan (CP) Team Meeting Notes (As updated during meeting) André Boudreau (a.boudreau@boroan.ca) Laura Heermann Langford (Laura.Heermann@imail.org) 2011-03-23 (No. 7) HL7 Patient Care Work Group

Agenda for March 23rd, 2011 Update on new wiki page for Care Plan initiative Review IHE approach to care coordination and planning, including the nursing perspective; assess reusability for our CP work Peter and co-chair of IHE AU Laura Heermann Langford, co-chair of PCCC Update from Danny on use cases Update on work with ONC team on transitions of care for the US and could report on that Start defining the in-scope and out-of-scope contents and aspects of care plan Then, decide on the deliverables and how we will produce the DAM

Agenda for March 30th Feedback on IHE PCC documents: quick overview and what is relevant to our CP (Stephen, Peter, Jay, Ian, Laura) Review of our deliverables (André) Updates on use cases Updated status on the wiki and uploaded documents Start surfacing the agenda for WGM in Orlando Check with William and Stephen (André) Who will be there? How much time do we want and to do what? 1 to 1,5 days? Tentative goal: ballot DAM in September, so we need a schedule

Done on March 16th Presentation by Canada (Ron Parker and Sasha Bojicic) on the COPD use case they developed: Done, see separate PP deck with discussion notes. See also the COPD use case document Next meeting (March 23rd): Review IHE approach to care coordination and planning, including the nursing perspective Peter and co-chair of IHE AU Laura Heermann Langford, co-chair of PCCC Start defining the in-scope and out-of-scope contents and aspects of care plan Update from Danny Then, decide on the deliverables and how we will produce the DAM

Participants- Meetg of 2011-03-23 p1 Name email Country Yes No Notes André Boudreau a.boudreau@boroan.ca CA Laura Heermann Langford Laura.Heermann@imail.org US Stephen Chu stephen.chu@nehta.gov.au AU Peter MacIsaac peter.macisaac@hp.com Adel Ghlamallah aghlamallah@infoway-inforoute.ca William Goossen wgoossen@results4care.nl NL Anneke Goossen agoossen@results4care.nl Ian Townsend ian.townend@nhs.net UK Rosemary Kennedy Rosemary.kennedy@jefferson.edu Jay Lyle jaylyle@gmail.com Margaret Dittloff mkd@cbord.com Audrey Dickerson adickerson@himss.org Ian McNicoll Ian.McNicoll@oceaninformatics.com Danny Probst Danny.Probst@imail.org Kevin Coonan Kevin.coonan@gmail.com

Participants- Meetg of 2011-03-23 p2 Name email Country Yes No Notes 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 Ray Simkus ray@wmt.ca CA Elayne Ayres EAyres@cc.nih.gov Lloyd Mackenzie lloyd@lmckenzie.com LM&A Consulting Ltd. Serafina Versaggi serafina.versaggi@gmail.com Sasha Bojicic SBojicic@infoway-inforoute.ca Lead architect, Blueprint 2015, Canada Health Infoway Agnes Wong awong@infoway-inforoute.ca RN, BScN, MN, CHE. Clinical Adoption - Director, Professional Practice & Clinical Informatics, Canada Health Infoway Cindy Hollister chollister@infoway-inforoute.ca RN, BHSc(N), Clinical Adoption -Clinical Leader, Canada Health Infoway Valerie Leung vleung@infoway-inforoute.ca Pharmacist. Clinical Leader, Canada Health Infoway Gordon Raup graup@comcast.net Was CEO, CareFacts Information Systems, Inc.

Notes on new wiki page Add team members that are regulars. Include profile notes.

IHE PCCP IHE 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) Scoped back for the USA 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

S&I Framework in the USA 3 topics: Transfer of care: 3 sub-groups Discharge summary Care plan Laura presented on what we are doing with CP. 3 calls with them since Identifying data elements and instructions Discharge summary is a retrospective view of transition data Would it contain care plan? Not settled where it sits Patient instructions is a prospective view and patient facing

Stephen [17:29:19] Stephen Chu: discharge summary is a retrospective (after the fact) but may contain care plan [17:30:24] Stephen Chu: allergy - is retrospective, it is a condition Important to be on prospective [17:30:54] Stephen Chu: adverse reaction is also retrospective, but assessment of future adverse reaction risk is prospective With the multiple care plan scenario that Laura mentioned - there will be a master care plan and subcare plans from collaborative care providers linked to the master care plan

Danny’s work on story boards 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

Need to understand contents enough to decide what is a must Stephen content - is the detail data collected as per patient management according to care plan structure - defines what a care plan will look like create, modify, update, transfer care plan , etc are dynamic behaviours

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,

Action Items as of 2011-03-23 No. Action Items By Whom For When Status 1. Clarify procedure and obtain rights for André/Laura to update CP wiki André Completed. New wiki page created 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) Outstanding - Request made 4 Prepare summary of the steps from HDF to produce the DAM Done. See Appendix 1 in first decks 5 Obtain and share the published version of the CEN Continuity of care P1 and P2; obtain ok from ISO Audrey/Laura Outstanding 6 Provide copy of the DAM presentation in Sydney and the name of a free mind mapping tool Stephen Done. Sent to list. 7 Update new wiki page with previous meeting material. Adjust structure of wiki. 8 Draft list of deliverables for this phase 9 Draft a new PSS and review with project group

Appendix

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