1. Care Plan (CP) Orlando WGM Meeting (With meeting notes) André Boudreau (a.boudreau@boroan.ca) Laura Heermann Langford (Laura.Heermann@imail.org) 2011-05-19, Q1, 9h00 to 10h30 Care Plan wiki: http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 http://wiki.hl7.org/index.php?title=Care_Plan_Initiative_project_2011 HL7 Patient Care Work Group There are facilities for remote participation for those who cannot be in Orlando: Teleconference: Call number: 770-657-9270, PIN 398644 Webex (thanks to Canada Health Infoway): https://infoway-inforoute.webex.com/infoway-inforoute/j.php?ED=160071542&UID=494535562&RT=NCMxMQ%3D%3D

2. Page 2 Agenda - May 19 th – Q1- 9h00 to 10h30 Attendance and agenda check - Laura (5) Background: history, need for a Care Plan DAM -André (5) Approach followed /deliverables – André (10) Status of Care Plan DAM project - André (5) Storyboard review: chronic care, home care - Laura (15) Sample of discussions: models, structures - Laura (15) Identifying key resources for the Care Plan DAM project – All participants (15)  Material and people from other Patient Care work (Pressure Ulcer, DCM) and other WG (Emergency Care, Care Provision, Care Statement, Structured Document, CDA consolidation, etc.) Suggestions and concerns of participants - Laura (15) Close -Laura (5)

3. Page 3 Participants- Meetg of 2011-05-19 p1 Nameemail Country YesNotes André Boudreau a.boudreau@boroan.ca 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 Laura.Heermann@imail.org 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 stephen.chu@nehta.gov.au 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 peter.macisaac@hp.com AU HP Enterprise Services. MD; Clinical Informatics Consultant; IHE Australia; Medical Practitioner - General Practice Adel Ghlamallah aghlamallah@infoway-inforoute.ca CA Canada Health Infoway. SME at Infoway (shared health record); past architect on EMR projects William Goossen wgoossen@results4care.nl 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 agoossen@results4care.nl NL 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 ian.townend@nhs.net UK NHS Connecting for Health. Health Informatics; Senior Interoperability Developer, Data Standards and Products; HL7 Patient Care Co-Chair Rosemary Kennedy Rosemary.kennedy@jefferson.edu US 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 jaylyle@gmail.com US JP Systems. Informatics Consultant; Business Consultant & Sr. Project Manager Margaret Dittloff mkd@cbord.com US The CBORD Group, Inc.. RD (Registered Dietitian); Product Manager, Nutrition Service Suite; HL7 DAM project for diet/nutrition orders; American Dietetic Association Audrey Dickerson adickerson@himss.org US 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 Ian.McNicoll@oceaninformatics.com UK Ocean Informatics. Health informatics specialist; Formal general medical practitioner; OpenEHR; Slovakia Pediatrics EMR; Sweden distributed care approach Danny Probst Daniel.Probst@imail.org US Intermountain Healthcare. Data Manager Kevin Coonan Kevin.coonan@gmail.com US MD. Emergency medicine. HL7 Emergency care WG. Gordon Raup graup@datuit.com US CTO, Datuit LLC (software industry). Susan Campbell bostoncampbell@mindspring.com US PhD microbiologist. Principal at Care Management Professionals. HL7 Dynamic Care Plan Co-developer Elayne Ayres EAyres@cc.nih.gov US 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

4. Page 4 Participants- Meetg of 2011-05-19 p2 Nameemail Country Yes 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 US Ray Simkus ray@wmt.ca CA Lloyd Mackenzie lloyd@lmckenzie.com CALM&A Consulting Ltd. Serafina Versaggi serafina.versaggi@gmail.com US Clinical Systems Consultant Sasha Bojicic SBojicic@infoway-inforoute.ca CALead 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 CAPharmacist. Clinical Leader, Canada Health Infoway Luigi Sison lsison@yahoo.com US 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.

5. Page 5 BACKGROUND

6. Page 6 History and Need for CP DAM Care Plan has been balloted some years ago as DSTU. However, it was felt at that time that more work needed to be done in defining care plan, the components of the care plan, identifying use cases and use. Items about Care Planning to be discussed towards a future round of DSTU include:  Existing RMIM: does it cover all kinds of care plans and pathways.  Definition of care plan  The overall structure that has been agreed: Care Plan -> Order set -> Clinical Statement. Discussion about this hierarchy is done in PC, O&O and CDS WG. Source: HL7 Patient Care WG Wiki

7. Page 7 Project Scope (2010) – to Be Updated 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, Generally a care plan greatly aids the team (responsible parties – it could be the patient caregiver/family) in understanding and coordinating the actions that need to be performed for the person. The Care Plan structure is used to define the management action plans for the various conditions identified for the target of care. It is the structure in which the care planning for all individual professions or for groups of professionals can be organized, planned and checked for completion. Communicating explicitly documented and planned actions and goals greatly aids the team in understanding and coordinating the actions that need to be performed for the person. Care plans also permit the monitoring and flagging of unperformed activities and unmet goals for later follow up. Source: HL7 Patient Care WG Wiki - Care Plan Topic project (Archived)

8. Page 8 APPROACH AND DELIVERABLES

9. Page 9 Approach The plan for 2011 is to first develop a Domain Analysis Model (DAM) for the Care Plan, and then decide on follow on activities. The HDF 1.5 (HL7 development framework) approach will be followed. HL7 PC will work together with various groups including HL7 Work Groups (e.g. EHR, Structured documents), IHE, NEHTA, Canada Health Infoway, and others.

10. Page 10 HDF- Domain Analysis Overview Source: HDF_1.5.doc, page 37 Last updated: 2011-02-09

11. Page 11 Requirements Document- Structure Business and clinical context, overall need Definition of the topic (theme) Stakeholders and needs Overall description of processes: contents dynamic, interchange Interrelationships with other processes Scope (in and out) Business objectives and outcomes Vision Statement

12. Page 12 PROGRESS AND STATUS OF CP DAM PROJECT

13. Page 13 Regular Participants at Weekly Meetings André Boudreau, Co-Lead Laura Heermann Langford, Co-Lead Stephen Chu, Patient Care WG Co-Chair Susan Campbell Kevin Coonan Margaret Dittloff Adel Ghlamallah Rosemary Kennedy Jay Lyle Ian McNicoll Danny Probst Luigi Sison, modeller

14. Page 14 Progress Achieved We clarified the process we would follow to conduct the Care Plan Domain Analysis We identified the storyboards required to cover the range of situations to be covered in the DAM We developed / refined 2 storyboards  Chronic care  Home Care We discussed and modeled the dynamics of care plans We looked at and compared the contents of some care plans: Sweden, IHE, NEHTA, Nursing We started drafting requirements

15. Page 15 STORYBOARD REVIEW Chronic Care Home Care

16. Page 16 List of Required Care Plan Storyboards Chronic Care Acute Care Home Care Perinatology Pediatric and Allergy/Intolerance Stay healthy

17. Page 17 Guiding Principles for Storyboards Describe a specific healthcare business problem (or processes) that require(s) the exchange of data/information By clinicians Need to ensure  Readability  Clinical accuracy, validity  Coverage (focus on the 80%, not the exceptions) Refined as we progress in the DAM process  Remember: storyboards get improved over time, as the project advances

18. Page 18 SAMPLE OF DISCUSSIONS REGARDING CARE PLAN DAM

19. Page 19 Dynamic Federated Plan of Care Model provided by Laura

20. Page 20 Dynamic Federated Plan of Care Model provided by Laura- Discussion This model illustrates a collaborative care model where the care plan is dynamically updated and maintained by multiple organizations and providers  Referral is connected to the plan The pink line shows the flow when there is no federated care plan  What is to be transmitted? The whole contents? Or the latest and most relevant data for the target organization/provider? We need to look at a typical chronic disease case where multiple organizations are involved without a federated care plan and no common system Sweden is moving to a patient centric model with a central dynamic care plan with greater fluidity of information among providers

21. Page 21 Types of care plans (provided by Stephen) Dynamic care plans  Care plans that are developed, shared, actioned and revise realtime by participating care providers via a collaborative (likely to be web-based) care plan management environment supported by complex workflow management engine. o dynamic and organic o coordinated by care coordinator (e.g. GP) o shared realtime o updated/managed realtime by all care provider o can contain other care plans o dynamic links to relevant patient information (where appropriate and feasible, i.e. privacy and security permit) and evidence-based resources Interchanged care plans  Care plans that are shared (preferrably via electronic exchanges) and actioned by participating care providers o lack support of a realtime collaborative care plan management environment o master care plan managed and updated/maintained mainly by a care coordinator (e.g. GP) with contributions from participating care providers o interchanged care plan is essentially a snap shot of the master care plan at a point in time o communicated often together with referral/request for services to target care providers o can contain other care plans as attachments Created: 2011-03-09

22. Page 22 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

23. Page 23 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

24. Page 24 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

25. Sample of Structure and Contents (xmind models) Ian McNicoll 2011-04-06

26. Sample of Structure and Contents (xmind models) Ian McNicoll 2011-04-06

27. Page 27 KEY RESOURCES FOR THE CARE PLAN DAM PROJECT

28. Page 28 Material and People SourceMaterialPeopleNotes Patient Care-DCM Patient Care-CP DSTU Patient care-Pressure Ulcer Care Statement Care Provision Structured Document CDA Templates Emergency care EHRS FM

29. Page 29 Discussion Notes- Key Resources for the Care Plan DAM Project

30. Page 30 SUGGESTIONS AND CONCERNS

31. Page 31 Suggestions and Concerns

32. Page 32 CONCLUSION

33. Page 33 Concluding Notes Reminder: Care Plan DAM weekly meetings  Wednesday, 17h00 EDT, 1.5 to 2 hours  All are welcome HL7 Wiki: Patient Care WG/ Care Plan Initiative 2011