Care Plan (CP) Team Meeting Draft

Care Plan (CP) Team Meeting Draft
Includes reference to EHR-S FM spreadsheet used by John, Pat and Sue (P. 9) Discussion notes updated using John’s notes and s from Kevin and Lenel (P. 10, 13-14) With meeting notes. Appendix 2 (summary of SAIF) added To join the meeting: Phone Number: Participant Passcode: WebEx link is on the wiki (link below) Care Plan (CP) Team Meeting Draft André Boudreau Laura Heermann Langford Stephen Chu (No. 20) Care Plan wiki: HL7 Patient Care Work Group

Agenda for August 17th Minutes of August 3rd (5 min.) Not done
Review of the HL7 EHR-S FM Care plan functionalities (30 minutes) EHR WG co-chairs and reps: John Ritter, Sue Mitchell, Pat Van Dyke, Lenel James Revision of the perinatology storyboard for presentation at the WGM (Laura) (30 min.) We will have one episode of care composed of a series of encounters. Throughout the episode, care plan information is exchanged, updated, and reported on. Agenda for the Care Plan quarter at the WGM (Q1, Thursday Sept. 15th): 9h00 to 10h30 PT (= 12h00 to 13h30 EDT) Stephen is looking into obtaining remote participation capabilities as in Orlando. Next meeting agenda (Aug. 31st) Do we also have a Sept. 7th meeting? If time permits: Storyboard document introduction (Andre): Not done Purpose, scope, guidelines, structure, quality criteria NOTE: Our focus up to WGM (week of Sept. 12th) will be on sharpening our definition of what our storyboards should be like, and on preparing one solid SB (perinatology) ready for review by clinical SMEs (not in the CS team). This material will be reviewed during the WGM before starting the clinical validation process.

Agenda for August 31st- tentative
Minutes of August 17rd (5 min.) Finalize perinatology storyboard for presentation at the WGM (Laura) (30 min.) Finalize agenda and slide deck for the Care Plan quarter at the WGM (Q1, Thursday Sept. 15th): 9h00 to 10h30 PT (= 12h00 to 13h30 EDT) Status on remote participation capabilities. Slide deck (André) Review of Home care plan and Chronic care plan SB Do we have a Sept. 7th meeting? We will likely cancel: confirm on Aug 31st. Next meeting agenda, post WGM (Sept. 28th): ok We will need a roadmap for Oct to Dec: André to draft Decide on future meetings and roles: every 2 weeks as in the summer If time permits: Storyboard document introduction (Andre) Purpose, scope, guidelines, structure, quality criteria

Updated HL7 v3 September 2011 ballot The September 2011 ballot is available at this link:

Future Topics Other SBs
Updated Future Topics Other SBs BPMN Models for the SBs (after SB validation and updates) Review of the ISO CONTSYS work on care plan aspects André to contact ISO Lead Care Plan elements from KP, Intermountain, VA, etc. (Laura) Requirements (André) Care Management Concept Matrix update (Susan) Comparison of care plan contents (Ian, Laura) To inform the information model Start of spreadsheet (Laura…) Overarching term to use (Ian M.) Care Plan Glossary Forward plan- first cut DONE Aug 17: Review of EHR-S FM R2 work by the HL7 EHR WG: Aug. 17, tentatively John Ritter, Sue Mitchell, Pat Van Dyke, Lenel James

Participants- WGM Meetg of 2011-08-17 p1
Name Country Yes Notes André Boudreau CA Co-Lead- Care Plan initiative/HL7 Patient Care WG. B.Sc.(Physics), MBA. Owner Boroan Inc. Management Consultin. Chair, Individual Care pan Canadian Standards Collaborative Working Group (SCWG). Sr project manager. HL7 EHR WG. Laura Heermann Langford US Co-Lead- Care Plan initiative/HL7 Patient Care WG. Intermountain Healthcare. RN PhD,: Nursing Informatics; Emergency Informatics Association, American Medical Informatics Association; IHE Stephen Chu AU NEHTA-National eHealth Transition Authority . RN, MD, Clinical Informatics; Clinical lead and Lead Clinical Information Architecture; co-chair HL7 Patient care WG; vice-chair HL7 NZ Peter MacIsaac HP Enterprise Services. MD; Clinical Informatics Consultant; IHE Australia; Medical Practitioner - General Practice Adel Ghlamallah Canada Health Infoway. SME at Infoway (shared health record); past architect on EMR projects William Goossen NL Results 4 Care B.V. RN, PhD; -chair HL7 Patient Care WG at HL7; Detailed Clinical Models ISO TC 215 WG1 and HL7 ; nursing practicioner Anneke Goossen Results 4 Care B.V. RN; Consultant; Co-Chair Technical Committee EHR at HL7 Netherlands; Member at IMIA NI; Member of the Patient Care Working Group at HL7 International Ian Townsend UK NHS Connecting for Health. Health Informatics; Senior Interoperability Developer, Data Standards and Products; HL7 Patient Care Co-Chair Rosemary Kennedy Thomas Jefferson University School of Nursing . RN; Informatics; Associate Professor; HL7 EHR WG; HL7 Patient care WG; terminology engine for Plan of care; Jay Lyle JP Systems. Informatics Consultant; Business Consultant & Sr. Project Manager Margaret Dittloff The CBORD Group, Inc.. RD (Registered Dietitian); Product Manager, Nutrition Service Suite; HL7 DAM project for diet/nutrition orders; American Dietetic Association Audrey Dickerson HIMSS. RN, MS; Standards Initiatives at HIMSS; ISO/TC 215 Health Informatics, Secretary; US TAG for ISO/TC 215 Health Informatics, Administrator; Co-Chair of Nursing Sub-committee to IHE-Patient Care Coordination Domain. Ian McNicoll Ocean Informatics . Health informatics specialist; Formal general medical practitioner; OpenEHR; Slovakia Pediatrics EMR; Sweden distributed care approach Danny Probst Intermountain Healthcare. Data Manager Kevin Coonan MD. Emergency medicine. HL7 Emergency care WG. Gordon Raup CTO, Datuit LLC (software industry). Susan Campbell PhD microbiologist. Principal at Care Management Professionals. HL7 Dynamic Care Plan Co-developer Elayne Ayres NIH National Institutes of Health. MS, RD; Deputy Chief, Laboratory for Informatics Development, NIH Clinical Center ; Project manager for BTRIS (Biomedical Translational Research Information System), a Clinical Research Data Repository Gaby Jewell Cerner Corp,

Participants- WGM Meetg of 2011-08-17 p2
Name Country Yes Notes David Rowed AU Charlie Bishop UK Walter Suarez US Peter Hendler Ray Simkus CA Lloyd Mackenzie LM&A Consulting Ltd. Serafina Versaggi Clinical Systems Consultant Luigi Sison Information Architect at LOINC and at HL7. Enterprise Data Architect at VA. Developing standard for Detailed Clinical Models (DCM), information models for Electronic Health Record (EHR) Diabetes Project, etc. Brett Esler Pen Computer Sys Catherine Hoang VA Hugh Leslie Seam Heard Thomson Kuhn Sr. Systems Architect at American College of Physicians Carolyn Silzle American Dietetic Association John Ritter Co-Chair - HL7 EHR WG and - PHR WG Patricia A. Van Dyke Co-Chair and Vocabulary Facilitator -HL7 EHR WG Sue Mitchell EHR WG since Was Project facilitator for the Long term care EHR Functional profile.

HL7 EHR-S FM Care Plan Functionalities
EHR WG co-chairs and representatives: John Ritter, Sue Mitchell, Pat Van Dyke, Lenel James

HL7 EHR-S FM- Discussion Notes -1
Updated HL7 EHR-S FM- Discussion Notes -1 See list of major Care Plan functionalities in the EHR-S FM R2 draft (still work in process) and the description and conformance criteria for the relevant care plan components of the Direct Care 1 and 2 sections of the Functional Model (FM): R2 Care Plan Functions (based on Public Comment Ballot reconciliation)(2).xlsx This document has been posted on the wiki There are 6 functions directly talking of care plan Other sections of the FM are generic and apply to numerous functions including Care plan: translation, RMES, Masking, etc. The EHR-S FM material is very informative for the Care Plan group Use the function descriptions and the Conformance Criteria to validate the CP storyboards Similarly, the Care Plan work can inform the EHR-S FM work The dynamics around the care plan The first Care Plan storyboard will be presented at the Sept. WGM In handling care plan information, there must be separation of ownership of data among the various care team members: who can modify or update what data HL7 already has role based and individual based access control Care team members can include family members, traditional medicine care providers, etc.

Summary of EHR-S FM Functionalities Related to Care Plan (John Ritter)
New Summary of EHR-S FM Functionalities Related to Care Plan (John Ritter) Creation/Import of a set of Care Plan (templates) Local tailoring of a given Care Plan template (form) by a user Selection of a given Care Plan template (form) Data Entry of Care Plan information View of another system’s Care Plan Communications between members of a Care Plan Clinical Decision Support that is based on a Care Plan Workflow and Business Rules based on a Care Plan Alerts and Notifications based on changes made to a Care Plan by one of the Care Team members Exchanging Care Plan information with a Personal Health Record system Translation of Care Plan information into other human languages Mapping of Care Plan information to local terms and/or codes Records Management and Evidentiary Support of Care Plan information Masking and hiding of certain data in a Care Plan Ordering Care Plans (for example, by date or status)

There are parts of the care plan that are shared and some that are not, e.g. for local micro management of activities Translation and mapping of terms must be very accurate for semantic interoperability. This can be quite challenging Is exchange of care plan information similar to referrals? The FM may need to add some functionality for dynamic updating of care plans The EHR WG is looking at new functionalities Recommendation for future care Referrals A UK group is looking at using social media to hold care team meetings to manage the care plan These may include or not the patient See these links: URL XYZ Suggestion by EHR WG: validate our work using the HL7 TSC Services Aware Interoperability Framework (SAIF) Note by André: see a SAIF summary in Appendix 2

For each of the functionalities, there needs to be an identification of the services required to carry out the function Also the static information component must be identified The EHR-S FM needs a comprehensive conceptual information model as a complement. This model would serve as a common foundation for all the individual initiatives in HL7 ISO has the Continuity of care concepts standards that it is updating (NWIP_13940_System_of_Concepts_to_support_continuity_of_care) The 2 parts have a comprehensive set of conceptual models Stephen P. Hufnagel has been working on an information model for the enterprise architecture. He is preparing a document for comments only at a future ballot cycle

Additional Discussion Notes from John
New Additional Discussion Notes from John Web services –related functionality would be quite helpful CPOE –related functionality would be helpful SAIF provides a good framework for asking and answering these types of questions Issue: Who is the actual owner (has the coordinating responsibility) of the Care Plan? Issue: Traditional Medicine (and other types of care givers – such as trusted neighbors) who offer healthcare to the patient, but who are not formal members of the Care Plan team HL7 has Role-Based Access Control (RBAC) (and individual-based) protocols The list of EHR-S FM functions (that deal with Care Plans) is fairly large, but the actual implementation of robust Care Plan system functionality (and supporting technical, legal, business, financial, etc., infrastructure) needs to catch up over the next few years. It would be good to scan the list of EHR-S FM Conformance Criteria and use them to spark various elements of the Patient Care Work Group’s new “Care Plan Storyboards”. It would be good to examine the HL7 Personal Health Record System Functional Model (to ensure that its Care-Plan –related functionality is also considered. NOTE: The next release of the EHR-S FM (called “Release 2”) may also have new functionality that ought to be considered by the PCWG. As the PCWG develops its Story Boards, it might be good to develop a White Paper (or “Parking Lot”) that can eventually inform other stakeholders of the need for them to create supporting structures (e.g., legal, financial, legislative, records-management, archiving, national health information networks, business, social network media, employers, payers) HL7 could develop a conceptual information model (per Andre)…

Additional Notes by Kevin Coonan and Lenel James (emails)
New Additional Notes by Kevin Coonan and Lenel James ( s) Kevin: It is crucial that we start to link all the functional requirements and profiles to the information models (DAMs?) they address and the workflow involved (BPMN--we should talk about any common patterns which can be reused and whether or not we need to customize it a bit for healthcare). Every functional requirement needs to detail the information, the services which would be used to compose the function, any required application behavior and what the clinical context/objective is. Lenel: It is an interesting idea, but if done, it should only be done in the context of a formal profile to the EHR-S FM. The standard is very clear, a system can only claim conformance to a profile, not the model. So, I would make the case that any DAM work would only be valuable in the context of the realm and/or care setting of a profile. A profile would be a much better basis for the clarity and specificity needed for information, services and application behaviors. Also, we have been clear in the EHR WG, in the EHR-S FM, in the HL7 classes, and in the HL7 Ambassador briefing that the EHR-S FM is not intended to be specifications for building software products. So, we would need to be careful in the scope and the intent of any potential DAM efforts.

Perinatology Storyboard
Detailed review Laura

Perinatology One episode of care (EOC) with multiple encounters
See definitions of encounter and EOC in Appendix See document by Laura. Updates done during the meeting. Next steps: Intro to be reworked by Laura Laura sends doc to PC list and Stephen Laura adds some description of the info that is exchanged among actors in each encounter Laura then sends this last version to the list before our next meeting, Aug. 31st Aug. 31st: we look at the last version and do final adjustments before WGM

WGM Care Plan Quarter (90 minutes)

WGM Care Plan Objectives and Agenda
Review our approach to storyboards (multiple encounters among multidisciplinary team of clinicians for one episode of care or one stream of condition management) Review one SB Review our approach to validation of the SB by clinicians Agenda Roll call (5 min.) Review of approach to structuring SBs (20 min.) Perinatology SB (45 min.) Plan for clinical validation of all SBs (20 min)

Conclusion

In process. EHR WG agreement received.
Updated Action Items as of No. Action Items By Whom For When Status Revise chronic disease SB to clearly identify related episodes and episode flow/transitions Stephen ASAP Tidy up perinatology SB Laura UML model of use cases: chronic disease and perinatology Danny / Laura Before 17 Aug 9 Draft a new PSS and review with project group André Deferred 10 Complete a first draft of requirements Started 12 Complete storyboards Multi 15 Organise and schedule a review of the Care Plan components of the EHR-S FM R2 In process. EHR WG agreement received. 16 Organise and schedule a review of the Care Plan components of ISO ContSys NB: Completed action items have been removed.

Appendix

Storyboard Vetting Process

Storyboard (SB) Validation & Approval
Clarify the guidelines and quality criteria for the Care Plan Storyboard (Care Plan Work Team CPWT) Assign a PCWT ‘owner’ for each SB (CPWT) For each SB, identify a validation group (3 to 5) of SMEs that include (CPWT) At least one physician, one nurse, and one other type of clinician that is described in the SB Representation from at least 2 countries Where possible and relevant, include a care coordinator/manager Obtain agreement to participate from SMEs (SB Owner) Communicate the criteria and the specific SB to the appropriate group of SMEs (SB Owner) Obtain individual feedback from the SMEs (SB Owner) Consolidate feedback and update the SB (SB Owner) Review the updated SB with the SMEs and the CPWT at a regular meeting (CPWT) Finalize the SB (SB Owner)

Care Plan Storyboard Guidelines and Quality Criteria
Focused on one typical story, not on exceptions Focused on the exchange of information about care plan Identifies what should be a best practice in the exchange of clinical information Is at the conceptual level, Is architecture, implementation and platform independent Is written in common clinical term, not in technical or IT terms Notes: Make explicit the state transitions? We will need to clarify the criteria for what is being sent in the information exchange, especially for patients with a long history Exclude patient profile, referral request Do not exclude application services related to care plan information exchange SB SME? MnM, Lloyd, Graham

Updated Storyboard Owners Owners are coordinators for the preparation, review and approval of SB, not experts in the domain Home Care: André SMEs: Acute Care Plan Storyboard: Danny/Kevin Perinatology: Laura Pediatric and Allergy/Intolerance: Susan Stay healthy: Laura Chronic disease: Stephen SMEs: Stephen + others

Appendix- HL7 Key terms This needs to be augmented for our Care Plan needs

Term: Patient encounter
Patient encounter is defined as an interaction between a patient and one or more healthcare practitioners for the purpose of providing patient services or assessing the health status of the patient. A patient encounter is further characterized by the setting in which it takes place; currently HL7 recognizes seven unique patient encounter types: Ambulatory Encounter - A comprehensive term for health care provided in a facility or setting that provides diagnostic, therapeutic and health maintenance services for persons not requiring stays that exceed 24 hours (e.g. a practitioner's office, clinic setting, or hospital) on a nonresident and non-emergency basis. The term ambulatory implies that the patient has come to the location and is not assigned to a bed. Sometimes referred to as an outpatient encounter. Emergency Encounter - A patient encounter that takes place at a dedicated healthcare service delivery location where the patient receives immediate evaluation and treatment, provided until the patient can be discharged or responsibility for the patient's care is transferred elsewhere (for example, the patient could be admitted as an inpatient or transferred to another facility.) Field Encounter - A patient encounter that takes place both outside a dedicated service delivery location and outside a patient's residence. Example locations might include an accident site or at a supermarket. Home Health Encounter - A patient encounter where services are provided or supervised by a practitioner at the patient's residence. Services may include recurring visits for chronic or terminal conditions or visits facilitating recuperation. Inpatient Encounter - A patient encounter where a patient is admitted by a hospital or equivalent facility, assigned to a location where patients generally stay at least overnight and provided with room, board, and continuous nursing service. Short Stay Encounter - A patient encounter where the patient is admitted to a health care facility for a predetermined length of time, usually less than 24 hours. Virtual Encounter - A patient encounter where the patient and the practitioner are not in the same physical location. Examples include telephone conference, exchange, robotic surgery, and televideo conference. Source: HL7 Version 3 Standard: Patient Administration Release 2; Patient Encounter, Release 1 DSTU Ballot 1 - May 2011

Term: Encounter Encounter
An Encounter (ENC) choice is an interaction between a patient and care provider(s) for the purpose of providing healthcare-related service(s). Healthcare-related services include health assessment. Note this type of statement covers admissions, discharges and transfers of care, as well as the more usual understanding of a single discrete office visit. It further deals with a plan for regular visits, such as preventive care during pregnancy, or monitoring of chronic ill patients. Includes requesting, proposing, promising, prohibiting or refusing an encounter as well as an actual encounter event. The encounter is a derivative of the RIM PatientEncounter class, used to represent related encounters, such as follow-up visits or referenced past encounters. Source: HL7 Draft Standard for Trial Use - HL7 Version 3 Standard: Clinical Statement Pattern, Release 1 - Last Published: 12/06/2007 10:24 AM

Term: Episode of Care - 1 An interval of care by a health care facility or provider for a specific medical problem or condition. It may be continuous or it may consist of a series of intervals marked by one or more brief separations from care, and can also identify the sequence of care (e.g., emergency, inpatient, outpatient), thus serving as one measure of health care provided. Note: may be one instance of care, a series of episodes or a sequence of care: read MeSH definition Sources: NLM Medical Subject Headings, NIH UMLS, FDA AERS The new Institute of Medicine definition of primary care requires that primary care clinicians address the large majority of personal health care needs of their patients. The unit of assessment for this is the episode of care, defined as a health problem from its first encounter with a health care provider through the completion of the last encounter. J Fam Pract Feb;42(2): Episode of care: a core concept in family practice.

Term: Episode of Care - 2 A defined period of illness that has a definite start and end date. Refers to all the health services related to the treatment of a condition. For acute conditions (such as a concussion or a broken bone), the episode includes all treatment and services from the onset of the condition to its resolution. ... the range of treatments provided over time for treating a condition or illness Treatment rendered in a defined time frame for a specific disease. Episodes provide a useful basis for analyzing quality, cost and utilization patterns.

Term: Episode of Care – Difficulties with the concept
Added on Term: Episode of Care – Difficulties with the concept The concept is easy to apply in acute care settings where there is a clear beginning and a clear end to the health issue/problem However, in chronic care situations, there is no clear end… The concept of condition management is more applicable to chronic care management For our chronic care plan, we will document a sample of encounters illustrative of a representative set of interactions among clinicians and the interchange of care plan information between them

Services Aware Interoperability Framework (SAIF)
A summary

SAIF Summary - 1 The Service-Aware Interoperability Framework (SAIF) goal is to create and manage easy-to-use, traceable, consistent and coherent Interoperability Specifications (ISs) regardless of the message, document or service interoperability-paradigm. The SAIF focus is on managing and specifying artifacts that explicitly express the characteristics of software components that affect interoperability. SAIF’s approach is to organize and manage architectural complexity with a set of constructs, best practices, processes, procedures and categorizations. SAIF’s scope is the interoperability space between system components. Specifically, SAIF manages the interworking among distributed systems that may involve information exchanges or service interactions and state changes; SAIF is not Enterprise Architecture . SAIF combines four sub-frameworks, that together form a basis for defining comparable interoperability specifications (Information and Behavioral Frameworks) and formalizing governance and conformity assessment methods (Governance and Enterprise Conformance and Compliance Frameworks) critical to defining and using interoperability specifications. Source: See also: HL7 SAIF Executive Summary and Implementation Guide.doc

SAIF Summary - 2 The Information Framework (IF) defines information models that specify the static semantics of interactions. This includes patterns for structured and unstructured data, documents, messages and services, metadata, quality measures and transformations. The IF scope includes the needs of direct clinical care, supportive and information infrastructure areas. The models, terminologies, vocabularies and value sets specify the static semantics for expressing concepts, relationships (including cardinalities), constraints, rules, and operations needed to specify data, data type bindings, vocabulary and value set bindings. The Behavioral Framework (BF) defines constructs that specify dynamic semantics of interactions in an interoperability specification. The BF focus is the accountability required to achieve working interoperability. Accountability is a description of “who does what when.” Accountability manifests itself as implicit or explicit contracts at the enterprise, business, capability, service and at the interface implementation levels. BF accountability is described by the relationships among various stakeholders and system components, applications and their system roles. These relationships involve information exchanges and state changes within use case scenarios. The Governance Framework (GF) purpose is to relate decisions and policies, to the IF and BF, managed within the ECCF. The GF scope includes core decision and configuration management processes concerning conformance, escalation, communication, vitality, and precepts . The GF defines expectations, grants power, verifies performance and manages configuration baselines. Governance consists of either a separate process or parts of management or leadership processes. Sometimes a governing board or council is set up to administer these processes and systems. The Enterprise Conformance and Compliance Framework (ECCF) goal is to ensure Working Interoperability (WI) among various healthcare organizations; WI is also known as compatibility among healthcare systems. The ECCF purpose is to manage the relationship between architectural artifacts and implementations of those artifacts. The objective of a fully qualified ECCF is to be a clear, complete, concise, correct, consistent and traceable interoperability specification, which is easy to use. The ECCF is an assessment framework, which supports configuration management baselines and risk assessments throughout a business-capability lifecycle. The ECCF is used to specify information exchange interoperability and conformance statements for documents, messages and services. The ECCF contains definitions of terms, such as conformance, compliance, consistency and traceability. An ECCF provides a template, called a Specification Stack (SS) that allows you to specify business objects, components, capabilities, applications and systems organized as a matrix of Reference Model Open Distributed Processing (RM-ODP) viewpoints and Model Driven Architecture (MDA) layers.

SAIF Summary - 3 Jointly, the IF and BF allow the specification of business objects, components, capabilities, applications, systems and their respective roles, responsibilities and information exchanges. The HL7 implementation of the IF and BF draws on storyboards, Domain Analysis Models (DAM), Detailed Clinical Models (DCM) and templates, Reference Information Model (RIM), vocabulary concepts, HL7 core principles plus message, document and service models. SAIF provides external stakeholders with a clear picture of exactly what is required to use and interoperate with an organization’s software components. A given component's specification is SAIF-compliant if it species "just enough" to enable the desired interoperability for the component as determined by how the capability is being used in its deployment context, such as within a lab, or within a wider enterprise community of partners.

Care Plan (CP) Team Meeting Draft

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