Longitudinal Coordination of Care Thursday, February 20, 2014 Care Plan Discussion with HL7 Patient Care WG

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TopicTime Welcome/Purpose of this Meeting5 mins HL7 PCWG’s recent changes to Care Plan modeling15 mins C-CDA R2 Implementation Guide’s changes in response to PCWG5 mins Discussion Points30 mins Next Steps / Meeting Reminders5 mins Agenda 3

Make everyone aware of the multiple industry initiatives around care plan exchange and standardization –ONC S&I Longitudinal Coordination of Care (LCC) has identified a Care Plan Exchange Use Case –HL7 Structured Documents (SDWG) has balloted an Implementation Guide for CDA Release 2: Consolidated Templates for Clinical Notes (based off the LCC Use Case) –HL7 Patient Care (PCWG) is developing SOA capabilities, models, user stories, story boards to support coordination of patient care across the continuum Purpose of this Meeting 4

HL7 PCWG 5

Issues regarding different types of "Care Plan" –The Care Plan project team accepts that the concepts: "Care Plan", "Plan of Care" and "Treatment Plan" are likely to be understood and used in different ways depending on the preference, culture, experiences, context of use, and funding models under which they operate. –Patient Care Workgroup (PCWG) acknowledges that: Care Plan, Plan of Care are often used interchangeably to mean the same thing Consolidated Plan, Care Plan are also used interchangeably to mean the same thing HL7 PCWG San Antonio WGM Discussion 6 nce_Call_Discussions/Resolutions

After 6+ months of intensive debates, the situation is still no closer to resolution and will likely remain so in foreseeable future, PCWG passed the following resolutions at the San Antonio meeting (January 2014): –The three types of plan (Care Plan, Plan of Care, Treatment Plan) will be removed from the Care Plan DAM. The different types of plan classes will also be removed from the logical and conceptual models. –Remove planClass (attribute): Plan Class Type and the three types of plans from the detailed model. –Preserve displayName (attribute) to allow naming of different types of care plan according to stakeholder practice/usage needs HL7 PCWG San Antonio WGM Resolutions (1) 7

–Review of storyboards to ensure that the contents adequately illustrate the use of the care plan model in the different contexts and different level of complexity that is congruent with the concepts: consolidate care plan, care plan, plan of care and treatment plan –There is a need to support nesting of [care] plan(s) within [care] plan. The next version of the DAM (May 2014 Ballot package) and the logical and implementable models to be developed will need to adequately and correctly illustrate how the nesting relationships should be represented If removing the three types of plans how will relationship be represented –Likewise, consideration should also be given to the structure of the care plan model on how to support linking different plans instead of nesting them i.e., the compositional issues of linking vs. association in the model will need to be analyzed and supported HL7 PCWG San Antonio WGM Resolutions (2) 8

Remove the three types of plan (Care Plan, Plan of Care, Treatment Plan) from the Care Plan Logical and Conceptual Models Remove the “planClass" attribute from the Care Plan Logical Model Add a “planCode” attribute to the Care Plan Logical Model to complement the "displayName" attribute, thus allowing machine processing TO DO: Address the issue of supporting "composition" and/or "association" between different types of plans in the model PCWG Care Plan DAM Changes 9

Care Plan DAM 10

The “disciplineCode" supports the expression of the clinical domain/discipline that has overall responsibility for the "Care Plan" (whether it is the care plan, plan of care, or treatment plan) –Examples: Neurosurgery, Orthopedic, Cardiology, Nephrology, Endocrinology, etc. Discussion: the word and description of disciplineCode suggests the care plan is clinically driven and omits the fact that the care plan can be patient or care team centered/driven. Suggest renaming and redefining this atribute. The “planCode" supports the inclusion of standard terminology/codes from authorized codesets, such as LOINC document codeset –The code may be used to represent a combination of discipline and types of plan Discussion: does LOINC support the number of codes needed to represent the variety of what “Plan” or “Care Plan” can actually mean? Laura Heerman Langford is working with the LOINC team and this is an opportunity to supply LOINC with a list of values we need. The "displayName" supports the expression of human readable concept names for the different care plans used by different stakeholders –Example: neurology spinal injury care plan; orthopedic spinal injury care plan; GP diabetic care plan, cardiology heart failure treatment plan, etc. Discussion: the word “displayName” can be confused to mean the coding system display name for a specific code. Suggest renaming this attribute. Linking “disciplineCode", “planCode”, “displayName" 11

HL7 C-CDA Templates Implementation Guide 12

We will adjust Care Plan Template description accordingly to comply with the alteration in the Care Plan DAM and associated descriptions. ClinicalDocument/code SHALL be the one to be provided by LOINC that = "Care Plan". To further align with PCWG resolution "- Preserve displayName (attribute) to allow naming of different types of care plan according to stakeholder practice/usage needs" we will define that the name of the type of Care Plan SHALL be present in ClinicalDocument/title to name the different types of care plan according to stakeholder practice/usage needs. –Discussion: What does the disciplineCode attribute from the PCWG model relate/map to in the C-CDA templates? Need answer from Lantana. Changes to the C-CDA R2 Implementation Guide 13

Discussion Points 14

How would the ending of a concurrent Care Plan be achieved in the HL7 Conceptual Care Plan Model? Through action of business rules? Discussion: CCS is discussing the option of a Discovery function to handle concurrent care plans. How would archiving a completed or decommissioned Care Plan be achieved in the HL7 Conceptual Care Plan Model? What does it mean to be archived? Final copy sent to patient via portal or PHR, notification sent to all Care Team Members, other known providers, and payers Or, just backed-up into a single cyberspace location that all can access (e.g. CCS? Databank?)? Discussion: The act of archival is an application-specific, local policy decision CCS takes that stance as well. Will include a note in the model to clearly state that position The PCWG conceptual model is designed to support static and dynamic aspects Archived= function being performed on a no longer active care plan (refer to the status) Discussion Points (1) 15

How would archiving a completed or decommissioned Care Plan be achieved in the Implementation Guide? Is there an appropriate CDA header to use in whatever template is considered the best one to accomplish the task? Are there usable or adaptable LOINC codes to select from for aspects of disposition of the Care Plan (e.g. permanently discontinued vs discontinued indefinitely vs temporarily suspended) or any of its individual “subplans” (Plans of Care) when only they rather than the entire Care Plan are retired? Discussion: The user would send an ActReference that shows that the care plan is completed. They may also indicate what it has been replaced by. Discussion Points (2) 16

Governance/management of the Care Plan and its subsets Who? By Patient decision By Provider assessment and decision (if it is a simple Care Plan, effectively equal to the Plan of Care and there are few to no other providers involved). By direct consideration of the Care Team during a team meeting, to notice and verify that a POC is low priority or not necessary. By bundled care payment mechanism. By algorithm and time frame such that for (e.g.) a pneumonia, by the end of 30 days it is considered complete if there has been no new charge for antibiotics or lab culture. Suggest implementing some tools (i.e., CCS project), then see how people innovate with them Discussion: The CCS model are constrained by governance rules based on where the model is implemented Constraints may also be patient based (prison status, foster care, etc) CCS and PCWG state that governance belongs to Policy and are staying out of government and regulatory policies. However, CCS and PCWG acknowledges these authorities in their models. Discussion Points (3) 17

How is governance handled in C-CDA? Discussion: When a care plan is exchanged via Direct, connect, fax – aren’t there governance business rules that flow through? C-CDA should not be concerned with governance. Currently there is governance around privacy and security, but not around the process (owner) governance. It is up for debate on where this needs to be discussed (CCS, ONC, etc) There are 3 role relationships that are required in a CDA document header (author, record target, custodian). Some of this comes down to state medical practice acts/laws. We need the type of information needed before guidance can be implemented. Wouldn’t state governance rules would be packaged with the method of transport? Discussion Points (4) NEW 18

Would this same mechanism or something like it be used to correct error(s) in the Care Plan? If so, at request of: Care Team members only (including patient or proxy)? Involved provider(s) not on the care team who are Care Plan recipients? Health Plan (if no representative on Care Team)? Machine-identified errors? Application or local policy Care Plan DAM contains mechanism to track versions and electronic trail Discussion: This would be handled the same way as archiving – it would be application-specific or set by local policy decision. Discussion Points (5) 19

Next Steps 20

HITPC ACO WG is launching a Care Plan Tiger Team Focused on Care Plans Bring in provider associations Moves beyond technical infrastructure of the standards LCC members to bring issues to Patient Care WG Schedule a monthly joint meeting Becky and Laura to coordinate day/time, but it sounds like the 3 rd Thursday from 5-6pm ET works for the majority. Next Steps 21

Meeting Reminders 22

The industry's largest health IT educational program and exhibition center February 23-27, 2014 in Orlando, FL ONC S&I Meet & Greet Tuesday, Feb. 25 th at 5pm at Rocks at the Hyatt Regency Health Story VIP Tours Tuesday, 8:30-9:30am Tuesday, 3:00-4:00pm Face-to-Face Session Wednesday, 2:30-4:00pm HIMSS Annual Conference & Exhibition 23

Meeting Reminders S&I Framework Hosted Meetings: LCC Pilot WG meetings are Mondays from 11:00– 12:00 pm Eastern –Focus on validation and testing of LCC Standards for Transitions of Care & Care Plan exchange HL7 Structured Documents WG Meetings Wednesdays from 3:00 – 4:00pm Eastern –URL: –Dial In: ; Access Code: –Focus on discussion of HL7 C-CDA R2 Ballot comments Thursdays from 10:00 – 12:00pm Eastern –WebEx: –Dial In: ; Access Code: –Focus on block voting of HL7 C-CDA R2 Ballot comments –As of 2/14, 928 of 1013 ballot comments have been reconciled

HL7 Patient Care WG Meeting Reminders Care Plan Project –Developing user stories that define and differentiate Care Plan, Plan of Care, Treatment Plan –Current working documents found here: –Meetings every other Wednesday from 4:00 – 5:00pm ET Next meeting scheduled for March 5 th Meeting Information: –Web Meeting URL: nehta.rbweb.com.aunehta.rbweb.com.au –Phone: , Participant Code:

HL7 Patient Care WG Meeting Reminders, cont’d... Health Concern Topic –Developing user stories highlighting the following: What is a Health Concern Observation; How Health Concern Tracker is Used; How Health Concern is different from Problem Concern –Current working documents found here: –Meetings every other Thursday from 4:00 – 5:00pm ET Next meeting scheduled for February 27 th Meeting Information: –Web URL: ber ber »Meeting Number: –Phone: , Participant Code:

HL7 Patient Care WG Meeting Reminders, cont’d... Coordination of Care Services Specification Project –Provide SOA capabilities/models to support coordination of patient care across the continuum –Current working documents found here: –Meetings every Tuesday 5:00 - 6:00 pm ET Meeting Information : –Web Meeting URL: 41XMZR3-3MNZ 41XMZR3-3MNZ »Meeting Number: –Phone: , Participant Code: