Care Plan (CP) Team Meeting Notes (As updated during meeting) André Boudreau Laura Heermann Langford (No. 7) HL7 Patient Care Work Group With 3 new pages (4, 5, 6) provided by Stephen: processes, structure, principles. These will be discussed on April 6th or 13th as time permits

Page 2 Agenda for March 23 rd, 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

Page 3 Agenda for March 30th Feedback on IHE PCC documents: quick overview and what is relevant to our CP (Stephen, peter, jay, ian) Review of our deliverables (André) Updates on deliverables 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 need schedule

Page 4 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

Page 5 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

Page 6 Care Plan Development - Principles High level processes can be used to guide storyboards, use cases and care plan structure development 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 Care plan should be goal/outcome oriented 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 Stephen Chu 5 April 2011

Page 7 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 23 rd ):  Review IHE approach to care coordination and planning, including the nursing perspective o Peter and co-chair of IHE AU o 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

Page 8 Participants- Meetg of p1 Name Country YesNoNotes André Boudreau CAYes Laura Heermann Langford USYes Stephen Chu AU Yes Peter MacIsaac AU Adel Ghlamallah CA Yes William Goossen NL Anneke Goossen NL Ian Townsend UK Rosemary Kennedy US Jay Lyle USYes Margaret Dittloff USYes Audrey Dickerson US Ian McNicoll UKYes Danny Probst US Kevin Coonan US

Page 9 Participants- Meetg of p2 Name Country YesNoNotes David Rowed AU Charlie Bishop UK Walter Suarez US Peter Hendler US Ray Simkus CA Elayne Ayres US Lloyd Mackenzie CALM&A Consulting Ltd. Serafina Versaggi US Sasha Bojicic CA Lead architect, Blueprint 2015, Canada Health Infoway Agnes Wong CA RN, BScN, MN, CHE. Clinical Adoption - Director, Professional Practice & Clinical Informatics, Canada Health Infoway Cindy Hollister CA RN, BHSc(N), Clinical Adoption -Clinical Leader, Canada Health Infoway Valerie Leung CA Pharmacist. Clinical Leader, Canada Health Infoway Gordon Raup US Was CEO, CareFacts Information Systems, Inc.

Page 10 Notes on new wiki page Add team members that are regulars. Include profile notes.

Page 11 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) 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

Page 12 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. o 3 calls with them since  Identifying data elements and instructions  Discharge summary is a retrospective view of transition data o Would it contain care plan? Not settled where it sits  Patient instructions is a prospective view and patient facing

Page 13 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 o Important to be on prospective  [17:30:54] Stephen Chu: adverse reaction is also retrospective, but assessment of future adverse reaction risk is prospective Stephen  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

Page 14 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

Page 15 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

Page 16 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,

Page 17 Action Items as of No.Action ItemsBy Whom For When Status 1.Clarify procedure and obtain rights for André/Laura to update CP wikiAndré 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)André Outstanding - Request made 4Prepare summary of the steps from HDF to produce the DAMAndré 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/LauraOutstanding 6 Provide copy of the DAM presentation in Sydney and the name of a free mind mapping tool StephenDone. Sent to list. 7Update new wiki page with previous meeting material. Adjust structure of wiki.André 8Draft list of deliverables for this phaseAndré 9Draft a new PSS and review with project groupAndré

Page 18 APPENDIX

Page 19 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

Page 20 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!

Page 21 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

Page 22 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: